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Original Question

Operative Report Date of Surgery: 05-22-YYYY Patient Name: Maxwell, Herman Gender: M Surgeon: Moody MD, William Unit-Case Study No: MC285-Unit 3-ASU Case Study 1 Preoperative Diagnosis: Iron deficiency anemia with hemoccult negative stools Postoperative Diagnosis: Rectosigmoid polyp times two at 12 and 15 cm. Remainder of colon normal to 40 cm Procedure: Flexible descending sigmoidoscopy to 60 cm Description of Procedure: This 50-year-old caucasian male patient with mild MR and spastic CP presented for annual recommended sigmoidoscopy at 50 yrs. Of age with a history of iron deficiency anemia and normal BE 1½ yrs. ago. He was prepped in the usual fashion, placed in the left lateral decubitus. Underwent digital rectal examination which was normal. The prostate was unremarkable. Anal anesthesia was applied with topical Benzocaine. The sigmoidoscope was then advanced to 60 cms. without difficulty. There was a lot of retained dry flaking stool in the descending colon. The rectosigmoid was examined on entrance and was followed throughout advancement of the sigmoidoscope. The actual extent of examination was probably to 40 cms. There was a lot of coiling of the sigmoidoscope and could not be advanced any further. The sigmoidoscope was then advanced. There is a small broad based polyp about 3 mm. in diameter that was on one of the mucosal folds at 12 cm it was biopsied and then in piecemeal fashion was removed using snare polypectomy. what are the two diagnostic codes

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