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: Eyelid Squamous Cell Carcinoma Excision

Description: Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Right upper eyelid squamous cell carcinoma.

POSTOPERATIVE DIAGNOSIS: Right upper eyelid squamous cell carcinoma.

PROCEDURE PERFORMED: Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.

COMPLICATIONS: None.

BLOOD LOSS: Minimal.

ANESTHESIA: Local with sedation.

INDICATION: The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids. The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.

Keywords: hematology - oncology, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis,
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