Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology

Specialty that treats diseases and pathology of the gastrointestinal tract, such as the esophagus, stomach and intestinal tract as well as diseases of the liver, gallbladder and pancreas.



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Laparoscopic Cholecystectomy & Appendectomy
Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her.

Laparoscopic Cholecystectomy & Cholangiogram
Laparoscopic cholecystectomy with cholangiogram. Acute gangrenous cholecystitis with cholelithiasis. The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.

Laparoscopic Cholecystectomy & Cholangiogram - 1
Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.

Laparoscopic Cholecystectomy & Liver Cyst Excision
Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.

Laparoscopic Gastric Bypass
Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.

Laparoscopic Gastric Bypass - 1
Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.

Laparoscopy & Laparoscopic Appendectomy
Diagnostic laparoscopy and laparoscopic appendectomy. Right lower quadrant abdominal pain, rule out acute appendicitis.

Laparoscopy & Sigmoidoscopy
Diagnostic laparoscopy and rigid sigmoidoscopy. Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.

Laparoscopy, Laparotomy, & Cholecystectomy
Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.

Liver Biopsy
Percutaneous liver biopsy. With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples