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: Surgery
Sample Name: Flex Sig - 3

Description: Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.
(Medical Transcription Sample Report)

PROCEDURE: Flexible sigmoidoscopy.

PREOPERATIVE DIAGNOSIS: Rectal bleeding.

POSTOPERATIVE DIAGNOSIS: Diverticulosis.

MEDICATIONS: None.

DESCRIPTION OF PROCEDURE: The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon. At this point, stool occupied the lumen, preventing further passage. The colon distal to this was well cleaned out and easily visualized. The mucosa was normal throughout the regions examined. Numerous diverticula were seen. There was no blood or old blood or active bleeding. A retroflexed view of the anorectal junction showed no hemorrhoids. He tolerated the procedure well and was sent to the recovery room.

FINAL DIAGNOSES:
1. Sigmoid and left colon diverticulosis.
2. Otherwise normal flexible sigmoidoscopy to the proximal descending colon.
3. The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.

RECOMMENDATIONS:
1. Follow up with Dr. X as needed.
2. If there is further bleeding, a full colonoscopy is recommended.

Keywords: surgery, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon,
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