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: Post Hemithyroidectomy

Description: The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

POSTOPERATIVE DIAGNOSES: Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

PROCEDURE: The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.

FINDINGS: Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.

ESTIMATED BLOOD LOSS: Approximately 10 mL.

FLUIDS: Crystalloid only.

COMPLICATIONS: None.

DRAINS: Rubber band drain in the neck.

CONDITION: Stable.

PROCEDURE: The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time.

Keywords: surgery, thyroid, rubber band drain, berry ligaments, papillary carcinoma, follicular variant, strap muscles, thyroid gland, sternocleidomastoid, parathyroid, hemithyroidectomy,
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