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: I&D - Buttock Abscess

Description: Incision and drainage (I&D) of buttock abscess.
(Medical Transcription Sample Report)

PRINCIPAL DIAGNOSIS: Buttock abscess, ICD code 682.5.

PROCEDURE PERFORMED: Incision and drainage (I&D) of buttock abscess.

CPT CODE: 10061.

DESCRIPTION OF PROCEDURE: Under general anesthesia, skin was prepped and draped in usual fashion. Two incisions were made along the right buttock approximately 5 mm diameter. Purulent material was drained and irrigated with copious amounts of saline flush. A Penrose drain was placed. Penrose drain was ultimately sutured forming a circular drain. The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis. Anesthesia, general endotracheal anesthesia. Estimated blood loss approximately 5 mL. Intravenous fluids 100 mL. Tissue collected. Purulent material from buttock abscess sent for usual cultures and chemistries. Culture and sensitivity Gram stain. A single Penrose drain was placed and left in the patient. Dr. X attending surgeon was present throughout the entire procedure.

Keywords: surgery, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage,
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