Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Dermatology
Sample Name: Biopsy - Skin Nevus

Description: Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Left back skin nevus 2 cm.
2. Right mid back skin nevus 1 cm.
3. Right shoulder skin nevus 2.5 cm.
4. Actinic keratosis left lateral nasal skin 2.5 cm.

POSTOPERATIVE DIAGNOSES:
1. Left back skin nevus 2 cm.
2. Right mid back skin nevus 1 cm.
3. Right shoulder skin nevus 2.5 cm.
4. Actinic keratosis, left lateral nasal skin, 2.5 cm.

PATHOLOGY: Pending.

TITLE OF PROCEDURES:
1. Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.
2. Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.
3. Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.
4. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.

ANESTHESIA: Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.

BLOOD LOSS: Minimal.

COMPLICATIONS: None.

PROCEDURE: Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.

Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.

Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin. The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.

Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to separate operative report for details. The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.

Keywords: dermatology, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps,
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