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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Laparoscopic Hysterectomy
Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.

Laparoscopic Supracervical Hysterectomy.
Laparoscopic supracervical hysterectomy. A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.

Pelvic pain, pelvic endometriosis, and pelvic adhesions. Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.

Laparoscopy - 1
Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case.

Laparoscopy - 2
Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.

Laparoscopy - 3
Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant. Chronic pelvic pain, probably secondary to endometriosis.

Laparoscopy - 4
Laparoscopy with ablation of endometriosis. Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.

Laparoscopy - Drainage of Cyst
Diagnostic laparoscopy and drainage of cyst.

Laparoscopy & Salpingo-oophorectomy
Laparoscopy with left salpingo-oophorectomy. Left adnexal mass/ovarian lesion. The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.

Laparotomy & Myomectomy
Laparotomy and myomectomy. Enlarged fibroid uterus and blood loss anemia. On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.

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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