Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology

The OB/GYN profession cares for women who are pregnant, during the prenatal, delivery and postnatal stages of pregnancy. Also treats diseases and provides routine physical care of the female reproductive system.



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Three-Week Postpartum Checkup
The patient comes for three-week postpartum checkup, complaining of allergies.

Total Abdominal Hysterectomy
Total Abdominal Hysterectomy (TAH). An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges.

Total Abdominal Hysterectomy - 1
Total abdominal hysterectomy.. Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.

Total Abdominal Hysterectomy - 2
Total abdominal hysterectomy. Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis. On laparotomy, the uterus did have multiple pedunculated fibroids.

Total Abdominal Hysterectomy - 3
Total abdominal hysterectomy (TAH) with a uterosacral vault suspension. Enlarged fibroid uterus and abnormal uterine bleeding.

Total Abdominal Hysterectomy - Followup
Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.

True Cut Needle Biopsy - Breast
True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.

Tubal Fulguration - Laparoscopic
Laparoscopic tubal fulguration.

Tubal Ligation
Laparoscopic bilateral tubal ligation with Falope rings.

Tubal Ligation - Laparoscopic
Desires permanent sterilization. Laparoscopic tubal ligation, Falope ring method. Normal appearing uterus and adnexa bilaterally.

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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