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: Pituitary Tumor Resection

Description: Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.
(Medical Transcription Sample Report)

TITLE OF OPERATION: Transnasal transsphenoidal approach in resection of pituitary tumor.

INDICATION FOR SURGERY: The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. She was started on Dostinex with increasing dosages. The most recent MRI demonstrated an increased growth with hemorrhage. This was then discontinued. Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion. All the risks, benefits, and alternatives were explained in great detail via translator.

PREOP DIAGNOSIS: Pituitary tumor.

POSTOP DIAGNOSIS: Pituitary tumor.

PROCEDURE DETAIL: The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine. The fluoroscope was then positioned. The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus. Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed. It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent. Once this was ensured and completed and hemostasis obtained, the wound was irrigated. There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate. The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure. All sponge and needle counts were correct. The patient was extubated and transported to the recovery room in stable condition. Blood loss was minimal.

Keywords: surgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary,
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