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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Proctitis & Proctocolitis
Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.

Progress Note - Liver Cirrhosis
Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.

Rectal Bleeding - 1-year-old
Pediatric Gastroenterology - Rectal Bleeding Consult.

Rectal Bleeding - Consult
A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks.

Sigmoidoscopy - 1
Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.

Small Bowel Obstruction
History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.

SOAP - Cholecystitis
She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.

Stamm Gastrostomy Tube Placement
Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy

Status Post Liver Transplant
A 10-year-old with a history of biliary atresia and status post orthotopic liver transplantation.

Surgical Closure of Gastrostomy
Closure of gastrostomy placed due to feeding difficulties.

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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