Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology

The OB/GYN profession cares for women who are pregnant, during the prenatal, delivery and postnatal stages of pregnancy. Also treats diseases and provides routine physical care of the female reproductive system.



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Culdoplasty & Vaginal Hysterectomy
Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy. Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.

D&C - Discharge Summary
Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.

D&C & Hysteroscopy
Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.

D&C & Hysteroscopy - 1
Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.

D&C & Hysteroscopy Followup
D&C and hysteroscopy. Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining. 6. Grade 1+ rectocele.

D&C & Laparoscopy
Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.

D&C & Laparoscopy - 1
Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis. Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.

D&C & Laparoscopy - 2
Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.

D&C & Tubal Pregnancy Removal
Complex right lower quadrant mass with possible ectopic pregnancy. Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.

D&C, Laparoscopy, & Salpingectomy
Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum. Pelvic pain, ectopic pregnancy, and hemoperitoneum.

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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