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SEER Training Modules

Manipulative Procedures Example 6

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Sigmoidoscopy Report

  • Red. No.: 000024
  • Name: Rollo Round
  • Age: 56
  • Sex: Male
  • Race: Black
  • Date: 2/8/91
  • Chief Complaint: Urgency
  • Referred by: Casey Good, MD
  • Previous Proctoscopy: Date None
  • Findings: ____________
  • Previous Rectal Surgery: None

History:

  1. Blood per rectum: Occasionally
  2. Abdominal_________
  3. Appetite Recent loss
  4. Abscess___________
  5. Itching____________
  6. Weight loss: 10 lbs.
  7. Protrusion___________
  1. Change in blowel habits: Decreasing caliber of stools
  2. Draining fistula __________
  3. Rectal pain_____________
  4. Fever_______________
  5. Constipation_____________
  1. Diarrhea: ___ Duration___ Constrant___ Periodic___ No. of Stools 3-4/day
    Blood ______ Mucus: Yes Cramps_________
  2. Laboratory: Frei _______ Serology____ Ova & Parasites________

Proctoscopy


  • Distance Scoped:_______ Interference: Yes
  • Mucosa: Normal______ Red____ Edematous____ Friable____
  • Ulcerated ____ Vascular Pattern____ Mucus____
  • Pus____ Blood______ Granular______ Glistening____

Description of Other Pathology and Remarks:

Procto exam unsatisfactory due to lack of prep. Digital rectal reveals 8-10 cm fungating posterolateral (L) lesion. Multiple biopsies taken through anoscope. Melanotic stool was noted to come from above the lesion.

Impression:

Carcinoma of rectum, R/O more proximal lesion.

Examined by: Adam Oma, MD