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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Low-Transverse C-Section - 8
Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization. Intrauterine pregnancy at 35-1/7. Rh isoimmunization. Suspected fetal anemia. Desires permanent sterilization.

Low-Transverse C-Section - 9
Primary low transverse cervical cesarean section. Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.

Low-Transverse C-Section & BTL
Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at term with previous cesarean section. Desires permanent sterilization. Macrosomia.

Low-Transverse C-Section & BTL - 1
Repeat low transverse cesarean section and bilateral tubal ligation (BTL). Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.

Lumbar Discectomy - Microscopic
Microscopic lumbar discectomy, left L5-S1. Extruded herniated disc, left L5-S1. Left S1 radiculopathy (acute). Morbid obesity.

Lumbar Discogram
Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.

Lumbar Laminectomy
Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.

Lumbar Laminectomy & Discectomy
Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.

Lumbar Laminotomy & Discectomy
Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.

Lumbar Puncture
Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak.

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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