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 - Axillary Lymph Node

Description: Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly. Right axillary lymph node biopsy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Right axillary adenopathy.
2. Thrombocytopenia.
3. Hepatosplenomegaly.

POSTOPERATIVE DIAGNOSES:
1. Right axillary adenopathy.
2. Thrombocytopenia.
3. Hepatosplenomegaly.

PROCEDURE PERFORMED: Right axillary lymph node biopsy.

ANESTHESIA: Local with sedation.

COMPLICATIONS: None.

DISPOSITION: The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

BRIEF HISTORY: The patient is a 37-year-old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly. The working diagnosis is lymphoma, however, the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis. Thus, the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery.

INTRAOPERATIVE FINDINGS: The patient was found to have a large right axillary lymphadenopathy, one of the lymph node was sent down as a fresh specimen.

PROCEDURE: After informed written consent, risks and benefits of this procedure were explained to the patient. The patient was brought to the operating suite, prepped and draped in a normal sterile fashion. Multiple lymph nodes were palpated in the right axilla, however, the most inferior node was to be removed. First, the skin was anesthetized with 1% lidocaine solution. Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla. Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node. The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab. Several hemostats were used, suture ligated with #3-0 Vicryl suture and hemostasis was maintained. Next the deep dermal layers were approximated with #3-0 Vicryl suture. After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending. The patient did tolerated the procedure well. Steri-Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition.

Keywords: surgery, hepatosplenomegaly, thrombocytopenia, axillary adenopathy, axillary lymph node biopsy, axillary lymph node, lymph node biopsy, lymph node, lymph, node, axillary, adenopathy, hemostasis, suture, 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