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 - 9

Description: Patient with history of polyps.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Prior history of polyps.

POSTOPERATIVE DIAGNOSIS: Small polyps, no evidence of residual or recurrent polyp in the cecum.

PREMEDICATIONS: Versed 5 mg, Demerol 100 mg IV.

REPORTED PROCEDURE: The rectal chamber revealed no external lesions. Prostate was normal in size and consistency.

The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum. The position of the scope within the cecum was verified by identification of the ileocecal valve. Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.

The cecum was extensively studied and no lesion was seen. There was not even a scar representing the prior polyp. I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all. The scope was then slowly withdrawn. In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma. It was freely mobile and very small with normal overlying mucosa. There was a similar lesion in the descending colon. Both of these appeared to be lipomatous, so no attempt was made to remove them. There were diverticula present in the sigmoid colon. In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery. There was no bleeding. The scope was then withdrawn. The rectum was normal. When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare. There was no specimen and there was no bleeding. The scope was then straightened, withdrawn, and the procedure terminated.

ENDOSCOPIC IMPRESSION:
1. Small polyps, sigmoid colon, resected them.
2. Diverticulosis, sigmoid colon.
3. Small rectal polyps, obliterated them.
4. Submucosal lesions, consistent with lipomata as described.
5. No evidence of residual or recurrent neoplasm in the cecum.

Keywords: surgery, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, 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.
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Transcribed Medical Transcription Sample Reports and Examples