Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Colonoscopy - 14

Description: Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.
(Medical Transcription Sample Report)

PREPROCEDURE DIAGNOSIS: History of colon polyps and partial colon resection, right colon.

POSTPROCEDURE DIAGNOSES:
1. Normal operative site.
2. Mild diverticulosis of the sigmoid colon.
3. Hemorrhoids.

PROCEDURE: Total colonoscopy.

PROCEDURE IN DETAIL: The patient is a 60-year-old of Dr. ABC's being evaluated for the above. The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some hemorrhoids. The scope was then removed. The patient tolerated the procedure well.

RECOMMENDATIONS: Repeat colonoscopy in three years.

Keywords: surgery, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid,
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