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: Flex Sig - 1

Description: Flexible sigmoidoscopy due to rectal bleeding.
(Medical Transcription Sample Report)

INDICATION: Rectal bleeding.

PREMEDICATION: See procedure nurse NCS form.

PROCEDURE: After informed consent was obtained from the patient, the patient was placed in the left lateral position. Digital rectal exam was performed revealing normal sphincter tone and no external hemorrhoids. A Pentax video endoscope was then inserted into rectum. The quality of the preparation was good. Under direct visualization, the endoscope was advanced to 60 cm from the anus without difficulty, and then slowly withdrawn, with careful examination of the colonic mucosa.

The mucosa was normal with the normal vascular pattern and no granularity, friability, or ulceration. There was no evidence of other polyps, masses, diverticula, or angiodysplasia. Retroflexion was performed in the rectum, and there were a few small white patches just at the anal verge. These were biopsied to rule out any abnormality and also internal hemorrhoids were noted. The colonoscope was then removed and the procedure was terminated.

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

1. White plaques at the anal verge, biopsied to rule out abnormality.
2. Internal hemorrhoids, otherwise normal flexible sigmoidoscopy.

PLAN: Continue fiber supplement as well as hyoscyamine. Await laboratory results. I will see her back in July 2005 when I return from maternity leave. If she has any problems during the interval when I am gone, she will follow up with any other physicians here in the office.

Keywords: gastroenterology, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal,
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