Transcribed Medical Transcription Sample Reports and Examples
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Gastroenterology

Multiple Medical Problems – Discharge Summary

Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia,
and congestive heart failure.

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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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Appendectomy – Laparoscopic

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

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Colonoscopy With Photos

Colonoscopy with photos. The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion.

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Esophagogastroduodenoscopy & Gastrostomy Tube Insertion

Esophagogastroduodenoscopy with photo. Insertion of a percutaneous endoscopic gastrostomy tube. Neuromuscular dysphagia. Protein-calorie malnutrition.

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Laparoscopic Cholecystectomy – 10

Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.

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