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: Tongue Lesion Biopsy

Description: Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. Right lateral base of tongue lesion, probable cancer.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Right lateral base of tongue lesion, probable cancer.

POSTOPERATIVE DIAGNOSIS: Right lateral base of tongue lesion, probable cancer.

PROCEDURE PERFORMED: Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.

ANESTHESIA: General.

FINDINGS: An ulceration in the right lateral base of tongue region. This was completely excised.

ESTIMATED BLOOD LOSS: Less than 5 mL.

FLUIDS: Crystalloid only.

COMPLICATIONS: None.

DRAINS: None.

CONDITION: Stable.

PROCEDURE: The patient placed supine in position under general anesthesia. First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated. The lesion in the tongue could be seen. Then, it was injected with 1% lidocaine and 1:100,00 epinephrine. After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total. Suction cautery was used for hemostasis. Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.

Keywords: hematology - oncology, excisional biopsy, tongue lesion, mouth, biopsy,
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