Medical Specialty:

Sample Name: Foreign Body Removal - Thigh

Description: Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle.
(Medical Transcription Sample Report)

PREPROCEDURE DIAGNOSIS: Foreign body of the right thigh.

POSTOPERATIVE DIAGNOSIS: Foreign body of the right thigh, sewing needle.

PROCEDURE: Removal of foreign body of right thigh.

HISTORY: This is a 71-year-old lady who has been referred because there is a mass in the right thigh. The patient comes with an ultrasound and apparently was diagnosed with a blood clot. On physical examination, blood pressure was 152/76 and temperature was 95.0. The patient is 5 feet 1 inch and weighs 170. On examination of her right thigh, there is a transverse area of ecchymosis in the upper third of the thigh. There is a palpation of a very sharp object just under the skin. The patient desires for this to be removed.

DESCRIPTION OF PROCEDURE: After obtaining informed consent in our office, the area was prepped and draped in usual fashion. Xylocaine 1% was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1-1/2-inch sewing needle.

Compression was applied for a few minutes and then a Band-Aid was applied.

The patient was given a tetanus toxoid 0.5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop.

Keywords: surgery, removal of foreign body, sewing needle, foreign body,