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: Gastroscopy - 1

Description: Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.
(Medical Transcription Sample Report)

PROCEDURE: Gastroscopy.

PREOPERATIVE DIAGNOSES: Dysphagia, possible stricture.

POSTOPERATIVE DIAGNOSIS: Gastroparesis.

MEDICATION: MAC.

DESCRIPTION OF PROCEDURE: The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.

FINAL DIAGNOSES:
1. Normal postoperative hernia repair.
2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.
3. Otherwise normal upper endoscopy to the descending duodenum.

RECOMMENDATIONS:
1. Continue proton pump inhibitors.
2. Use Reglan 10 mg three to four times a day.

Keywords: surgery,
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