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: Biopsy - Actinic Keratosis

Description: Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Left chest actinic keratosis, 2 cm.
2. Left medial chest actinic keratosis, 1 cm.
3. Left shoulder actinic keratosis, 1 cm.

POSTOPERATIVE DIAGNOSES:
1. Left chest actinic keratosis, 2 cm.
2. Left medial chest actinic keratosis, 1 cm.
3. Left shoulder actinic keratosis, 1 cm.

TITLE OF PROCEDURES:
1. Excisional biopsy of left chest 2 cm actinic keratosis.
2. Two-layer plastic closure.
3. Excisional biopsy of left chest medial actinic keratosis 1 cm with one-layer plastic closure.
4. Excisional biopsy of left should skin nevus, 1 cm, one-layer plastic closure.

ANESTHESIA: Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 6 mL.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

PROCEDURE: All areas were prepped, draped, and localized in the usual manner. Afterwards, elliptical incisions were placed with a #15-blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions. After all were removed, they were closed with one-layer technique for the shoulder and medial lesion, and the larger left chest lesion was closed with two-layer closure using Monocryl 5-0 for subcuticular closure and 5-0 nylon for skin closure. She tolerated this procedure very well, and postoperative care instructions were provided. She will follow up next week for suture removal. Of note, she had an episode of hemoptysis, which could not be explained prompting an emergency room visit, and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made.

Keywords: surgery, two-layer plastic closure, one-layer plastic closure, skin nevus, actinic keratosis, plastic closures, keratosis, actinic, biopsy, forceps, layer, closures, chest,
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