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: Rectal Bleeding - Consult

Description: A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks.
(Medical Transcription Sample Report)

REASON FOR ADMISSION: Rectal bleeding.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physical therapy for his lower back secondary to pain after hernia repair. He states that the pain worsened after this. He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal. He denies any dysuria. He denies any hematemesis. He denies any pleuritic chest pain. He denies any hemoptysis.

PAST MEDICAL HISTORY:
1. History of bilateral hernia repair by Dr. X in 8/2008.
2. History of rectal bleeding.

ALLERGIES: NONE.

MEDICATIONS:
1. Cipro.
2. Lomotil.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: No tobacco, alcohol or IV drug use.

REVIEW OF SYSTEMS: As per the history of present illness otherwise unremarkable.

PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is afebrile. Pulse 117, respirations 18, and blood pressure 117/55. Saturating 98% on room air.
GENERAL: The patient is alert and oriented x3.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear without exudates.
NECK: Supple. No thyromegaly. No jugular venous distention.
HEART: Tachycardic. Regular rhythm without murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally both anteriorly and posteriorly.
ABDOMEN: Positive bowel sounds. Soft and nontender with no guarding.
EXTREMITIES: No clubbing, cyanosis or edema in the upper or lower extremities.
NEUROLOGIC: Nonfocal.

LABORATORY STUDIES: Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils. EKG shows sinus tachycardia.

PROBLEM LIST:
1. Colitis.
2. Sepsis.
3. Rectal bleeding.

RECOMMENDATIONS:
1. GI consult with Dr. Y's group.
2. Continue Levaquin and Flagyl.
3. IV fluids.
4. Send for fecal WBCs, O&P, and C. diff.
5. CT of the abdomen and pelvis to rule out abdominal pathology.
6. PPI for PUD prophylaxis.

Keywords: gastroenterology, stomach discomfort, colitis, sepsis, hernia repair, rectal bleeding, hernia, diarrhea, stomach,
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