LOM FILES

INTRO_1

OPERATIVE REPORT

UPPER ENDOSCOPY NOTE

INDICATIONS:  This 47-year-old white female was referred for evaluation of intermittent bright red rectal bleeding.  The patient was evaluated 2 years ago when she had significant rectal bleeding with gross hematochezia.  At that time, colonoscopy was normal.  The bleeding was so severe that the required 2 units of packed RBCs in transfusion.  The patient has had another episode subsequently without seeking medical attention.  When she had another episode in the last month, she ought followup.

The patient also described lower abdominal discomfort, which is a burning sensation.  She has not noted any effect by food ingestion.  There is no previous history of peptic ulcer disease.  The patient feels that the bleeding often will be heralded by this abdominal discomfort.  In light of these findings, upper endoscopy as well as colonoscopy was recommended to the patient.  The risks of bleeding were discussed, and the patient agrees to proceed.

PREMEDICATION:  Demerol 60 mg I.V., Versed 3 mg I.V. with saline flush.

FINDINGS:  The Olympus XQ upper endoscope was inserted under direct vision.  The hypopharynx appears normal.  The esophagus shows normal mucosa throughout, with the Z-line pristine.  The stomach shows a small amount of bile-tinged fluid which is easily aspirated.  The mucosa in the stomach is completely normal including retroflexed view of the angularis, body, fundus, and EG junction.  The pylorus is patent and easily allows passage of the endoscope.  The duodenum shows normal mucosa of the bulb and C-loop to the distal second portion.  Patient tolerated the procedure well.

ASSESSMENT:  Normal upper GI endoscopy.

INTRO_4

USING MEDICAL REFERENCES

Not many years ago, patient records within both hospitals and the offices of physicians in private practice were kept informally and somewhat casually.  The medical secretary was often too busy to take on the task of record keeping, and not infrequently the doctor’s wife would come to the office once or twice a week to bring the patients’ records up-to-date.  The physician, making rounds at the hospital, would scribble a few notes on patients’ charts. These notes were meaningful to him but often indecipherable to anyone else.  Writing good case reports by hand was time-consuming and pretty far down on the list of medical priorities for the physician.

Advancement and progress in research, the division of medicine into highly specialized fields, and the needs of clinical investigators have now made strict accuracy and careful detail necessary in medical recordkeeping.  No longer are a few scribbled notes acceptable.

In the same way that medical practice has become more precise in its documentation, medical transcription has become more complex in its demands.  A number of years ago, the only word sources besides a medical dictionary were lists of words compiled by transcriptionists themselves.  Today, medical reference books are vitally important to medical transcriptionists.

Medical dictionaries will always be needed, but transcriptionists themselves have recognized the need for other ways to quickly locate sought-after terms.  By making personal lists of unfamiliar and difficult medical words and by doing additional research in journals and textbooks, some transcriptionists, such as myself, have actually been instrumental in the introduction of new word books specifically designed to meet the needs of medical transcriptionists.

Become familiar with your medical reference books.  Take time to examine them to see how they are organized so that you can efficiently look up new medical words.  Use your medical reference books constantly to improve your expertise as a transcriptionist.  Up-to-date, well-used references are the sign of a well-informed, professional medical transcriptionist.