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 - 1

Description: Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.
(Medical Transcription Sample Report)

INDICATION: Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.

PREMEDICATION: See procedure nurse NCS form.

PROCEDURE: After informed consent was obtained, the patient was placed in the left lateral position and the above medications were titrated with adequate sedation. Monitoring was provided throughout the entire procedure. Digital rectal exam was performed revealing normal sphincter tone and no external hemorrhoids. The Pentax video colonoscope was inserted into rectum and advanced under direct visualization, without difficulty, to the cecum, where the cecal strap, appendiceal orifice, and the ileocecal valve were identified. The quality of the preparation was good. The colonoscope was then withdrawn while carefully examining the mucosa.

The colonic mucosa appeared normal with normal vascularity and haustral markings. No masses, polyps, AVM/s or diverticula were seen. On retroflexed view in the rectum, there are small internal hemorrhoids.

The endoscope was removed and the procedure terminated. The patient tolerated the procedure well without complications.

IMPRESSION:
1. Small internal hemorrhoids.
2. Otherwise normal colonoscopy.

PLAN: Continue fiber, increase to two tablets twice a day for a total of four tablets. Also try NuLev.

FOLLOWUP: In the office in approximately four weeks if her symptoms do not resolve.

Keywords: surgery, bleeding, ct scan, digital rectal exam, pentax video, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constipation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral position, bowel disease, internal hemorrhoids, inflammatory,
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