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: Foreign Body Removal - Thigh

Description: Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle.
(Medical Transcription Sample Report)

PREPROCEDURE DIAGNOSIS: Foreign body of the right thigh.

POSTOPERATIVE DIAGNOSIS: Foreign body of the right thigh, sewing needle.

PROCEDURE: Removal of foreign body of right thigh.

HISTORY: This is a 71-year-old lady who has been referred because there is a mass in the right thigh. The patient comes with an ultrasound and apparently was diagnosed with a blood clot. On physical examination, blood pressure was 152/76 and temperature was 95.0. The patient is 5 feet 1 inch and weighs 170. On examination of her right thigh, there is a transverse area of ecchymosis in the upper third of the thigh. There is a palpation of a very sharp object just under the skin. The patient desires for this to be removed.

DESCRIPTION OF PROCEDURE: After obtaining informed consent in our office, the area was prepped and draped in usual fashion. Xylocaine 1% was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1-1/2-inch sewing needle.

Compression was applied for a few minutes and then a Band-Aid was applied.

The patient was given a tetanus toxoid 0.5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop.

Keywords: surgery, removal of foreign body, sewing needle, foreign body,
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