Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology
Sample Name: Endoscopy

Description: Upper gastrointestinal endoscopy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Anemia.

PROCEDURE: Upper gastrointestinal endoscopy.

POSTOPERATIVE DIAGNOSES:
1. Severe duodenitis.
2. Gastroesophageal junction small ulceration seen.
3. No major bleeding seen in the stomach.

PROCEDURE IN DETAIL: The patient was put in left lateral position. Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction. Advanced into the upper part of the stomach into the antrum. The duodenum showed extreme duodenitis and the scope was then brought back. Retroflexion was performed, which was normal. Scope was then brought back slowly. Duodenitis was seen and a little bit of ulceration seen at GE junction.

FINDING: Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.

Keywords: gastroenterology, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding,
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