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Strategies for Establishing and Managing a Home-Based Medical Transcription Business
by Kristine Showalter

SAMPLE TRANSCRIPTION REPORT

ULTRASOUND RETROPERITONEUM RENAL 0/00/2008

HISTORY:

80 year old female with a history of left kidney mass on prior ultrasound from Anywhere Medical Center on 0/00/0007.

COMPARISON STUDY:

None. Prior report of the ultrasound from Anywhere, Medical Center on 0/00/0007 is available for comparison.

FINDINGS:

The left kidney measures approximately 10.0 cm in length x 4.0 cm in anterior posterior dimension. Along the mid-upper portion of the left kidney there is a small echogenic focus measuring approximately 6.5 mm without posterior acoustic shadowing. This may signify an angiomyolipoma which was mentioned on an earlier exam. At that time it measured approximately 4 mm, (note although this may be a technique difference). Mild extrarenal pelvis prominence is seen. The right kidney measures approximately 13.6 cm in length x 5.9 cm anterior posterior dimension. There is a large solid hypoechoic mass measuring approximately 7.2 x 6.4 cm with some internal calcification that demonstrates posterior acoustic shadowing. This lesion is primarily at the mid-inferior pole. Underlying renal cell carcinoma should be considered until proven otherwise. The urinary bladder is unremarkable.

IMPRESSION:

There is a large 6.4 x 7.2 cm solid mass seen within the right kidney. Underlying renal cell carcinoma should be considered until proven otherwise. Its size is not significantly changed when compared to prior exam from Anywhere Medical Center. Focal echogenic focus measuring approximately 6 mm is seen at the left kidney which may represent angiomyolipoma. Further evaluation with CT examination is recommended at this time.

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