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 - Keratotic Neoplasm

Description: Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.
2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.
3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.

POSTOPERATIVE DIAGNOSES:
1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.
2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.
3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.

TITLE OF PROCEDURES:
1. Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.
2. Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.
3. Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.

ANESTHESIA: Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS: Less than 30 mL.

COMPLICATIONS: None.

PROCEDURE: The patient was evaluated preoperatively and noted to be in stable condition. Informed consent was obtained from the patient. All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. Each of the areas was cleaned with a sterile alcohol swab. Planned excision site was marked with a marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.

We began first with excision of the left temple followed by the left nasolabial and right temple lesions. The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. However, it is somewhat deeper than the standard seborrheic keratosis. The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.

Excision of left cheek was a keratotic nevus. It was excised with a defect 0.5 x 0.5 cm. It was closed in a single layer fashion 5-0 nylon.

The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. Sterile dressing was applied afterwards. The patient was discharged in stable condition. Postop care instructions reviewed in detail. She is scheduled with me in one week and we will make further recommendations at that time.

Keywords: surgery, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision,
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