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: Breast Biopsy

Description: Excisional breast biopsy with needle localization. The skin overlying the needle tip was incised in a curvilinear fashion.
(Medical Transcription Sample Report)

PROCEDURE PERFORMED: Excisional breast biopsy with needle localization.

ANESTHESIA: General.

PROCEDURE: After informed consent was obtained, the patient was brought to the radiology suite where needle localization was performed with mammographic guidance. I reviewed the localizing films with the radiologist, and the patient was then brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.

The skin overlying the needle tip was incised in a curvilinear fashion. Dissection down to the needle tip was performed using a combination of Metzenbaum scissors and Bovie electrocautery. Every attempt was made to get approximately 1 cm of normal tissue around the lesion. The wire was released and the lesion having been excised was removed from the wound and sent to Radiology for confirmation of excision. The wound was copiously irrigated with sterile water, and hemostasis was obtained using Bovie electrocautery. Once Radiology called and confirmed complete excision of the mass, the skin incision was approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin and Steri-Strips were applied. A dressing was then applied. All surgical counts were reported as correct.

Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.

Keywords: surgery, curvilinear fashion, bovie electrocautery, breast biopsy, needle localization, needle tip, curvilinear, breast, biopsy, needle,
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