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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Lower Quadrant Pain
Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear.

Melena - ICU Followup
Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.

Multiple Medical Problems - Discharge Summary
Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.

Nissen Fundoplication
Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.

Open Cholecystectomy
Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.

Pancreatic Mass - Discharge Summary
The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.

Paracentesis
Paracentesis. A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.

Paracentesis - Ultrasound-Guided
Ultrasound-Guided Paracentesis for Ascites

PEG Tube
Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.

Postop Transanal Excision
Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.

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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