Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Hematology - Oncology
Sample Name: Excision of Squamous Cell Carcinoma

Description: Re-excision of squamous cell carcinoma site, right hand.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma on the right hand, incompletely excised.

POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma on the right hand, incompletely excised.

NAME OF OPERATION: Re-excision of squamous cell carcinoma site, right hand.

ANESTHESIA: Local with monitored anesthesia care.

INDICATIONS: Patient, 72, status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb. The deep margin was positive. Other margins were clear. He was brought back for re-excision.

PROCEDURE: The patient was brought to the operating room and placed in the supine position. He was given intravenous sedation. The right hand was prepped and draped in the usual sterile fashion. Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath. The tissue was passed off the field as a specimen.

The wound was irrigated with warm normal saline. Hemostasis was assured with the electrocautery. The wound was closed with running 3-0 nylon without complication. The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.

Keywords: hematology - oncology, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma,
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