Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Surgery
Sample Name: Chest Wall Mass Removal

Description: Removal of chest wall mass. The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Chest wall mass, left.

POSTOPERATIVE DIAGNOSIS: Chest wall mass, left.

PROCEDURE: Removal of chest wall mass.

DESCRIPTION OF PROCEDURE: After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic. The time-out process was followed and preoperative antibiotics were given. The patient was in the supine position and was prepped and draped in the usual fashion.

The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected. An incision was made directly on the mass and carried down to the ribs. This is where the several chondral cartilages of the lower ribs meet. So I believe they were isolated in 9th rib anteriorly and I was able to encircle it. The medial area was __________. There was no way to perform same procedure there, so what I did, I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs. There was also a separate sharp growth of the mass growing superiorly. Apparently, I was able to excise the mass and actually it was much larger than it was palpated externally. This may be due to an extension towards the inside of his chest. Hemostasis was revised. The internal mammary was intact and there was no obvious penetration of the pleural cavity. The specimen was sent to Pathology and then we proceeded to close the defect. Obviously, the space between the ribs cannot be approximated. So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl.

The patient tolerated the procedure well. Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.

Keywords: surgery, chest wall mass, local anesthetic, lower ribs, chest wall, mass, cartilages, wall, chest, ribs,
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.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples