Sample Name: Scalp Mole Skin Biopsy
Description: Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.
(Medical Transcription Sample Report)
PROCEDURE: Skin biopsy, scalp mole.
INDICATION: A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.
PROCEDURE NOTE: The patient's scalp hair was removed with:
1. K-Y jelly.
2. Betadine prep locally.
3. A 1% lidocaine with epinephrine local instilled.
4. A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound. Hemostasis was controlled. The patient tolerated the procedure.
PLAN: The patient will have sutures removed in 10 days.
Keywords: dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,