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

Description: Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.
(Medical Transcription Sample Report)

DIAGNOSIS: Stasis ulcers of the lower extremities

OPERATION: Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.

INDICATIONS: This 84-year old female presented recently with large ulcers of the lower extremities. These were representing on the order of 50% or more of the circumference of her lower leg. They were in a distribution to be consistent with stasis ulcers. They were granulating nicely and she was scheduled for surgery.

FINDINGS: Large ulcers of lower extremities with size as described above. These are irregular in shape and posterior and laterally on the lower legs. There was no evidence of infection. The ultimate skin grafting was quite satisfactory.

PROCEDURE: Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes. The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin. The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed. Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch. This was meshed 1:1.5 and then stapled into position on the wounds. The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.

She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels. The donor site was dressed with Op-Site. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.

Keywords: surgery, skin graft, lower extremities, split thickness skin grafting, skin grafting, kerlix, grafting, extremities, ulcers, leg,
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