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: Colonoscopy with Biopsy - 1

Description: The patient with a recent change in bowel function and hematochezia.
(Medical Transcription Sample Report)

PREPROCEDURE DIAGNOSIS: Change in bowel function.

POSTPROCEDURE DIAGNOSIS: Proctosigmoiditis.

PROCEDURE PERFORMED: Colonoscopy with biopsy.

ANESTHESIA: IV sedation.

POSTPROCEDURE CONDITION: Stable.

INDICATIONS: The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is here for colonoscopy. He understands the risks and wishes to proceed.

PROCEDURE: The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation. Digital rectal examination was performed, which showed no masses, and a boggy prostate. The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum. In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis. Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.

RECOMMENDATIONS: Follow up with me in 2 weeks and we will begin Canasa suppositories.

Keywords: gastroenterology, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,
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