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: SOAP - Cholecystitis

Description: She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.
(Medical Transcription Sample Report)

SUBJECTIVE: She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.

PHYSICAL EXAMINATION:
VITAL SIGNS: Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.
LUNGS: Clear to auscultation. No wheezes, rales, or rhonchi.
HEART: Regular rhythm and rate.
ABDOMEN: Soft, less tender.

LABORATORY DATA: Her white count continues to come down. Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000. We have ordered type and cross for 2 units of packed red blood cells. If it drops below 25, she will receive a transfusion. Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7. Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.

ASSESSMENT AND PLAN: She had a bowel movement today and is continuing to improve.

I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.

Keywords: gastroenterology, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis,
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