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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Delivery Note - 9
She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.

Diagnostic Laparoscopy
The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.

Diagnostic Laparoscopy - 1
Diagnostic laparoscopy. Acute pelvic inflammatory disease and periappendicitis. The patient appears to have a significant pain requiring surgical evaluation. It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.

Diagnostic Mammogram
Diagnostic Mammogram and ultrasound of the breast.

Dilatation & Curettage - D&C
Fractional dilatation and curettage

Dilation & Evacuation
Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.

Ectopic Pregnancy - Discharge Summary
A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.

Emergency C-section.
Emergency cesarean section.

Endometrial Cancer Followup
Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.

Exploratory Laparotomy - 2
Exploratory laparotomy. Extensive lysis of adhesions. Right salpingo-oophorectomy. Pelvic mass, suspected right ovarian cyst.

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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