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: Sebaceous Cyst Excision

Description: Excision of sebaceous cyst, right lateral eyebrow.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Sebaceous cyst, right lateral eyebrow.

POSTOPERATIVE DIAGNOSIS: Sebaceous cyst, right lateral eyebrow.

PROCEDURE PERFORMED: Excision of sebaceous cyst, right lateral eyebrow.

ASSISTANT: None.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

ANESTHESIA: General endotracheal anesthesia.

CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: Stable. Transferred to the recovery room.

INDICATIONS FOR PROCEDURE: The patient is a 4-year-old with a history of sebaceous cyst. The patient is undergoing PE tubes by Dr. X and I was asked to remove the cyst on the right lateral eyebrow. I saw the patient in my clinic. I explained to the mother in Spanish the risk and benefits. Risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery. We will proceed with the surgery.

PROCEDURE IN DETAIL: The patient was taken into the operating room, placed in the supine position. General anesthetic was administered. A prophylactic dose of antibiotic was given. The patient was prepped and draped in a usual manner. The procedure began by infiltrating lidocaine with epinephrine around the cyst area. Then, I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point. The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst. The cyst was detached of the surrounding structure with the help of blunt dissection. Hemostasis was achieved with electrocautery. The wound was closed with 5-0 Vicryl deep dermal interrupted stitches and Dermabond. The patient tolerated the procedure well without complications and transferred to recovery room in stable condition. I was present and participated in all aspects of the procedure. Sponge, needle, and instrument counts were completed at the end of the procedure.

Keywords: surgery, lateral eyebrow, excision of sebaceous cyst, sebaceous cyst, cyst, eyebrow, sebaceous,
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