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: Punch Biopsy - 2

Description: Worrisome skin lesion. A punch biopsy of the worrisome skin lesion was obtained. Lesion was removed.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Worrisome skin lesion, left hand.

POSTPROCEDURE DIAGNOSIS: Worrisome skin lesion, left hand.

PROCEDURE: The patient gave informed consent for his procedure. After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.

Local anesthetic medication was infiltrated around and into the area of interest. There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma. A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included. The predominant portion of the biopsy was of the lesion itself.

Lesion was removed. Attention was turned toward the area. Pressure was held and the area was hemostatic.

The skin and the area were closed with 5-0 nylon suture. All counts were correct. The procedure was closed. A sterile dressing was applied. There were no complications. The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.


Keywords: surgery, skin lesion, squamous cell carcinoma, punch 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