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

The branch of medical science that treats disease or injury by operative procedures.



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Laparoscopy - Drainage of Cyst
Diagnostic laparoscopy and drainage of cyst.

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

Laparoscopy & Salpingo-oophorectomy
Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.

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.

Laparotomy & Myomectomy
Laparotomy and myomectomy. Enlarged fibroid uterus and blood loss anemia. On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.

Laparotomy & Salpingectomy
Exploratory laparotomy and right salpingectomy.

Laryngectomy & Thyroid Lobectomy
Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.

Laryngoscopy
Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.

Laryngoscopy & Vocal Cord Biopsy
Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping. Hoarseness, bilateral true vocal cord lesions, and leukoplakia.

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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