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: Excision - Actinic Neoplasm

Description: Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.
2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.
3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.
4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.
5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.

POSTOPERATIVE DIAGNOSES:
1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.
2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.
3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.
4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.
5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.

TITLE OF PROCEDURES:
1. Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.
2. Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.
3. Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.
4. Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.
5. A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.

ANESTHESIA: Local. I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS: Less than 30 mL.

COMPLICATIONS: None.

COUNTS: Sponge and needle counts were all correct.

PROCEDURE: The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc. The areas of concern were marked with the marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.

I began excising the left upper cheek and left lower cheek neck lesions as listed above. These were excised with the #15 blade. The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm. A suture was placed at the 12 o'clock superior margin. Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma. The healthy margin of healthy tissue around this lesion was removed. Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.

The left upper neck lesion was also removed in the similar manner. This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis. It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm. After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.

The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit. These appeared to be clinically seborrheic keratotic neoplasms.

Finally proceeded with the right cheek lesion, which was treated with the 50% TCA. This was also an actinic keratosis. It is new in onset, just within the last week. Once a light frosting was obtained from the treatment site, bacitracin ointment was applied. Postop care instructions have been reviewed in detail. The patient is scheduled a recheck in one week for suture removal. We will make further recommendations at that time.

Keywords: surgery, skin neoplasm, actinic neoplasm, seborrheic, keratosis, verrucous seborrheic keratosis, two-layer plastic closure, shave excision, superior pinna auricular rim, deep subcutaneous, plastic closures, seborrheic keratosis, neck, neoplasm, cheek, actinic,
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