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 - 2

Description: Colonoscopy in a patient with prior history of anemia and abdominal bloating.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: Prior history of anemia, abdominal bloating.

POSTOPERATIVE DIAGNOSIS: External hemorrhoids, otherwise unremarkable colonoscopy.

PREMEDICATIONS: Versed 5 mg, Demerol 50 mg IV.

REPORT OF PROCEDURE: Digital rectal exam revealed external hemorrhoids. The colonoscope was inserted into the rectal ampulla and advanced to the cecum. The position of the scope within the cecum was verified by identification of the appendiceal orifice. The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal. The scope was retroflexed in the rectum and no abnormality was seen. So the scope was straightened, withdrawn, and the procedure terminated.

ENDOSCOPIC IMPRESSION:
1. Normal colonoscopy.
2. External hemorrhoids.

Keywords: surgery, colonoscopy, digital rectal exam, abdominal, anemia, ascending colon, bloating, cecum, colonoscope, descending colon, hemorrhoids, hepatic flexure, rectal ampulla, rectum, splenic flexure, transverse colon, external hemorrhoids, scope,
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