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: Mohs Micrographic Surgery - 1

Description: Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.
(Medical Transcription Sample Report)

PREOP DIAGNOSIS: Basal Cell CA.

POSTOP DIAGNOSIS: Basal Cell CA.

LOCATION: Mid parietal scalp.

PREOP SIZE: 1.5 x 2.9 cm

POSTOP SIZE: 2.7 x 2.9 cm

INDICATION: Poorly defined borders.

COMPLICATIONS: None.

HEMOSTASIS: Electrodessication.

PLANNED RECONSTRUCTION: Simple Linear Closure.

DESCRIPTION OF PROCEDURE: Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.

The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.

No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.

Keywords: dermatology, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage,
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