Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery

The branch of medical science that treats disease or injury by operative procedures.



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I&D - Gluteal Abscess
Incision and drainage (I&D) of gluteal abscess. Removal of pigtail catheter. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.

I&D - Neck Abscess
Incision and drainage of left neck abscess.

I&D - ORIF Wound
Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.

I&D - Penoscrotal Abscess
Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.

I&D - Perirectal Abscess
Perirectal abscess. Incision and drainage (I&D) of perirectal abscess.

I&D & Foreign Body Removal
Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.

I&D & Open Reduction - Forearm
Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast.

I&D & Wound Closure - Scalp Lacerations
Incision and drainage (I&D) with primary wound closure of scalp lacerations. The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.

Iliac Artery Catheter & Stent Placement, Arteriography, Angioplasty
Placement of right external iliac artery catheter via left femoral approach, arteriography of the right iliac arteries, primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon, open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.

Iliac Crest Bone Graft - Maxilla & Mandible
Autologous iliac crest bone graft to maxilla and mandible under general anesthetic. Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.

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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