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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C. Diff Colitis Consult
The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.

Cecal Polyp Resection
Laparoscopic resection of cecal polyp. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.

Cholangiocarcinoma Consult
Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.

Cholecystectomy - Open
Open cholecystectomy (attempted laparoscopic cholecystectomy).

Cholecystectomy & Cholangiogram.
Laparoscopic cholecystectomy with cholangiogram.

Cholecystectomy Laparoscopic
Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.

Cholecystitis - Discharge Summary
Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.

Cholecystostomy Tube Placement
Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis.

Clostridium Difficile Colitis Followup
Still having diarrhea, decreased appetite.

Colon Cancer Consult
Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.

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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