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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Nissen Fundoplication
Nissen fundoplication. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.

Odontogenic Abscess I&D
Left facial cellulitis and possible odontogenic abscess. Attempted incision and drainage (I&D) of odontogenic abscess.

Olecranon Bursa - Excision
Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.

Ommaya reservoir
Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.

Open Cholecystectomy
Acute acalculous cholecystitis. Open cholecystectomy. The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.

Open Plantar Fasciotomy
Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.

Orchiectomy
Bilateral scrotal orchiectomy

Orchiectomy & Testis Fixation
Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.

Orchiopexy
Left orchiopexy. Ectopic left testis. The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.

Orchiopexy - Bilateral
Bilateral orchiopexy. This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.

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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