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: Colonoscopy - 20

Description: Screening colonoscopy. Tiny polyps. If adenomatous, repeat exam in five years.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Screening.

POSTOPERATIVE DIAGNOSIS: Tiny Polyps.

PROCEDURE PERFORMED: Colonoscopy.

PROCEDURE: The procedure, indications, and risks were explained to the patient, who understood and agreed. He was sedated with Versed 3 mg, Demerol 25 mg during the examination.

A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum. It was passed to the level of the cecum. The ileocecal valve was identified, as was the appendiceal orifice.

Slowly withdrawal through the colon revealed a small polyp in the transverse colon. This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps. In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon. This was also removed using the cold biopsy forceps. Further detail failed to reveal any other lesions with the exception of small hemorrhoids.

IMPRESSION: Tiny polyps.

PLAN: If adenomatous, repeat exam in five years. Otherwise, repeat exam in 10 years.


Keywords: surgery, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, 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