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SEER Training Modules

Manipulative Procedures Example 5

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Sigmoidoscopy Report

  • Red. No.: 000023
  • Name: Lil Massey
  • Age: 70
  • Sex: Female
  • Race: Black
  • Date: 3/4/91
  • Chief Complaint: Recent change in bowel habits - alternating constipation and diarrhea
  • Referred by: Uriah Hurtt. MD
  • Previous Sigmoidoscopy: No date
  • Findings: ____________
  • Previous Rectal Surgery: None

History:

  1. Blood per rectum: None noted
  2. Abdominal colic: None
  3. Appetite: Recent loss
  4. Abscess___________
  5. Itching____________
  6. Weight loss: 5 lbs.
  1. Protrusion: None
  2. Change in bowel habits: Alternating
  3. Draining fistula__________
  4. Rectal pain_____________
  5. Fever______________
  6. Constipation: See 8 above
  1. Diarrhea: _X_ Duration___ Constrant___ Periodic: _X_ No. of Stools___
    Blood: _None noted_ Mucus _______ Cramps _______
  2. Laboratory: Frei _______Serology _______Ova & Parasites ________


Sigmoidoscopy:

  • Distance scoped: 25 cm
  • Interference: 0

Mucosa: Normal: _X_ Red____ Edematous ____ Friable ____
Ulcerated ____ Vascular Pattern ____ Mucus ____
Pus ____ Blood ______ Granular ______ Glistening ____

Description of Other Pathology and Remarks:

  • Rectal - Large, firm, fungating mass on ant, (L) and post. wall of rectum
  • Anoscopy - Same. No ulcerations. Bx's taken.
  • Sigmoidoscopy - Fungating, lobulated mass from anal verge to 10 cm on ant, (L) and post. rectal wall. No other lesions seen.

Examined by: Willa Prospect, MD