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: Sacral Decubitus Debridement

Description: Stage IV necrotic sacral decubitus. Debridement of stage IV necrotic sacral decubitus.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Stage IV necrotic sacral decubitus.

POSTOPERATIVE DIAGNOSIS: Stage IV necrotic sacral decubitus.

PROCEDURE PERFORMED: Debridement of stage IV necrotic sacral decubitus.

GROSS FINDINGS: This is a 92-year-old African-American female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul-smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm. A long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy.

OPERATIVE PROCEDURE: The patient was properly prepped and draped under local sedation. A 0.25% Marcaine was injected circumferentially around the necrotic decubitus. A wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed. All bleeding was cauterized with electrocautery and then a Kerlix stack was then placed and a pressure dressing applied. The patient was sent to recovery in satisfactory condition.

Keywords: surgery, diverting colostomy, sacral decubitus debridement, necrotic sacral decubitus, wound, tissue, debridement, sacral, decubitus, necrotic,
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