Sample Type / Medical Specialty: Surgery
Sample Name: Skin Biopsy
The skin biopsy was performed on the right ankle and right thigh. The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.
(Medical Transcription Sample Report)
The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. The skin biopsy was performed on the right ankle and right thigh.PROCEDURE:
The site was cleaned with antiseptic. A local anesthetic (2% lidocaine) was given at each site. A 3 mm punch biopsy was performed in the left calf and left thigh, above the knee. The site was then checked for bleeding. Once hemostasis was achieved, a local antibiotic was placed and the site was bandaged.
The patient was not on any anticoagulant medications. There were also no other medications which would affect the ability to conduct the skin biopsy. The patient was further instructed to keep the site completely dry for the next 24 hours, after which a new Band-Aid and antibiotic ointment should be applied to the area. They were further instructed to avoid getting the site dirty or infected. The patient completed the procedure without any complications and was discharged home.
The biopsy will be sent for analysis.
The patient will follow up with Dr. X within the next two weeks to review her results.
surgery, antiseptic, local anesthetic, hemostasis, punch biopsy, band-aid, skin biopsy,
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