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: Lipoma Excision

Description: Intramuscular lipoma, right upper extremity. Excision of intramuscular lipoma with flap closure.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Mass lesion, right upper extremity.

POSTOPERATIVE DIAGNOSIS: Intramuscular lipoma, right arm, approximately 4 cm.

PROCEDURE PERFORMED: Excision of intramuscular lipoma with flap closure by Dr. Y.

INDICATIONS FOR PROCEDURE: This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity. The mass has been increasing in size and symptoms according to the patient. The risks and benefits of the surgical excision were discussed. The patient gave informed consent for surgical removal.

GROSS FINDINGS: At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps. It was removed in its entirety and submitted to Pathology for appropriate analysis.

PROCEDURE: The patient was taken to the operating room. She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion. Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity. The skin and subcutaneous tissue were incised as well as the muscular fascia. The fibers of the biceps were divided bluntly and retracted. The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures. The mass was submitted to Pathology. Good hemostasis was seen. The wound was irrigated and closed in layers. The deep muscular fascia was reapproximated with #2-0 Vicryl suture.

The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture. Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion. The patient was given wound care instructions and will follow up again in my office in one week. Overall prognosis is good.

Keywords: surgery, excision, mass lesion, intramuscular, muscular fascia, vicryl suture, intramuscular lipoma, suture, mass, lipoma,
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