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: Postop Transanal Excision

Description: Bleeding after transanal excision five days ago. Exam under anesthesia with control of bleeding via cautery. The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Bleeding after transanal excision five days ago.

POSTOPERATIVE DIAGNOSIS: Bleeding after transanal excision five days ago.

PROCEDURE: Exam under anesthesia with control of bleeding via cautery.

ANESTHESIA: General endotracheal.

INDICATION: The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding. Digital exam reveals bright red blood on the finger. He is for exam under anesthesia and control of hemorrhage at this time.

FINDINGS: There was an ulcer where most of the polypoid lesion had been excised before. In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa. There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture. No other obvious bleeding was seen.

TECHNIQUE: The patient was taken to the operating room and placed on the operative table in supine position. After adequate general anesthesia was induced, the patient was then placed in modified prone position. His buttocks were taped, prepped and draped in a sterile fashion. The anterior rectal wall was exposed using a Parks anal retractor. The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery. There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well. This was controlled with a 3-0 Monocryl figure-of-eight suture. At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition.

Keywords: gastroenterology, diarrhea, anterior base lesion, polypoid lesion, transanal excision, transanal, anesthesia, bleeding,
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