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: Scalp Mole Skin Biopsy

Description: Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.
(Medical Transcription Sample Report)

PROCEDURE: Skin biopsy, scalp mole.

INDICATION: A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.

PROCEDURE NOTE: The patient's scalp hair was removed with:
1. K-Y jelly.
2. Betadine prep locally.
3. A 1% lidocaine with epinephrine local instilled.
4. A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound. Hemostasis was controlled. The patient tolerated the procedure.

IMPRESSION: Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.

PLAN: The patient will have sutures removed in 10 days.

Keywords: dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,
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