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 - Skin Neoplasm

Description: Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Enlarging nevus of the left upper cheek.
2. Enlarging nevus 0.5 x 1 cm, left lower cheek.
3. Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.

TITLE OF PROCEDURES:
1. Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.
2. Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.
3. Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.

ANESTHESIA: Local. I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS: Less than 10 mL.

COMPLICATIONS: None.

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. Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed. Each of these lesions appears to be benign nevi; however, they have been increasing in size. The lesions involving the left upper and lower cheek appear to be deep. These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision. Each of these lesions was marked. The skin was cleaned with a sterile alcohol swab. Local anesthetic was infiltrated. Sterile prep and drape were then performed.

Began first excision of the left upper cheek skin lesion. This was excised with the 15-blade full thickness. Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.

The lesion of the lower cheek was removed in a similar manner. Again, it was excised with a 15 blade with two layer plastic closure. Both these lesions appear to be fairly deep nevi.

The right nasal ala nevus was superficially shaved using the radiofrequency wave unit. Each of these lesions was sent as separate specimens. The patient was discharged from my office in stable condition. He had minimal blood loss. The patient tolerated the procedure very well. Postop care instructions were reviewed in detail. We have scheduled a recheck in one week and we will make further recommendations at that time.

Keywords: surgery, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek,
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