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: I&D - Perirectal Abscess

Description: Perirectal abscess. Incision and drainage (I&D) of perirectal abscess.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Perirectal abscess.

POSTOPERATIVE DIAGNOSIS: Perirectal abscess.

PROCEDURE: Incision and drainage (I&D) of perirectal abscess.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room after obtaining an informed consent. A spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.

Prior to prepping, I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope. I found some small internal hemorrhoids and no fistulous tracts.

Then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained. All necrotic tissue was debrided. The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area. The cavity was irrigated with saline and then was packed with iodoform gauze and dressed.

Estimated blood loss was minimal. The patient tolerated the procedure well and was sent for recovery in satisfactory condition.

Keywords: surgery, hemorrhoids, incision and drainage, perirectal abscess, cavity, i&d, perirectal,
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