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 - Soft Tissue Mass

Description: Excision of soft tissue mass on the right flank. This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Right flank subcutaneous mass.

POSTOPERATIVE DIAGNOSIS: Right flank subcutaneous mass.

PROCEDURE PERFORMED: Excision of soft tissue mass on the right flank.

ANESTHESIA: Sedation with local.

INDICATIONS FOR PROCEDURE: This 54-year-old male was evaluated in the office with a large right flank mass. He would like to have this removed.

DESCRIPTION OF PROCEDURE: Consent was obtained after all risks and benefits were described. The patient was brought back into the operating room. The aforementioned anesthesia was given. Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion. With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank. Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass. The incision was extended down using electrocautery. The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle. The mass was sent off to Pathology for investigation. Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion. The patient's wound was cleaned. Steri-Strips were placed and sterile dressings were placed on top of this. The patient tolerated the procedure well and will reevaluate in the office in one week's time.

Keywords: surgery, electrocautery, soft tissue mass, subcutaneous, 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