Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology

Specialty that treats diseases and pathology of the gastrointestinal tract, such as the esophagus, stomach and intestinal tract as well as diseases of the liver, gallbladder and pancreas.



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Abdominal Abscess I&D
Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.

Abdominal Exploration
Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak. Diffuse intestinal and mesenteric lymphangiectasia.

Abdominal Pain - Consult
The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

Abscess Excision
Excision of abscess, removal of foreign body. Repair of incisional hernia. Recurrent re-infected sebaceous cyst of abdomen. Abscess secondary to retained foreign body and incisional hernia.

Admission History & Physical - Nausea
Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

Adrenalectomy & Umbilical Hernia Repair
Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.

Air Under Diaphragm - Consult
Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.

Appendectomy
Appendicitis, nonperforated. Appendectomy. A transverse right lower quadrant incision was made directly over the point of maximal tenderness.

Appendectomy - 1
Acute appendicitis, gangrenous. Appendectomy.

Appendectomy - Laparoscopic
Laparoscopic appendectomy and peritoneal toilet and photos. Pelvic inflammatory disease and periappendicitis.

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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