Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Gastroenterology
Sample Name: Colonoscopy

Description: Iron deficiency anemia. Diverticulosis in the sigmoid.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Iron deficiency anemia.

POSTOPERATIVE DIAGNOSIS: Diverticulosis.

PROCEDURE: Colonoscopy.

MEDICATIONS: MAC.

PROCEDURE: The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. Preparation was good, although there was some residual material in the cecum that was difficult to clear completely. The mucosa was normal throughout the colon. No polyps or other lesions were identified, and no blood was noted. Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation. A retroflex view of the anorectal junction showed no hemorrhoids. The patient tolerated the procedure well and was sent to the recovery room.

FINAL DIAGNOSES:
1. Diverticulosis in the sigmoid.
2. Otherwise normal colonoscopy to the cecum.

RECOMMENDATIONS:
1. Follow up with Dr. X as needed.
2. Screening colonoscopy in 2 years.
3. Additional evaluation for other causes of anemia may be appropriate.

Keywords: gastroenterology, olympus, colonoscope, iron deficiency anemia, diverticulosis, sigmoid, cecum, anemia, colonoscopy,
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.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples