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Repair of Lip Laceration Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Complex near amputation/laceration, right lower lip.

POSTOPERATIVE DIAGNOSIS:
Complex near amputation/laceration, right lower lip.

PROCEDURE PERFORMED:
Repair of complex laceration, right lower lip.

SURGEON:  John Doe, MD

INDICATIONS:  The patient is a (XX)-year-old male who was bitten by his friend's dog, sustaining a near amputation of the lower third of the right lower lip.

Physical examination in the emergency room revealed the right lower third of the lower lip hanging by a pedicle off the oral commissure. The laceration extended from the commissure down the chin and angling back up towards the one-third border of the lower lip. A second laceration was full thickness, extending from the inferior labial sulcus through the lip and down onto the chin. A further laceration of approximately 3 cm was found to be present along the gingival border of the inferior labial sulcus.

DESCRIPTION OF PROCEDURE:  The patient underwent sterile prep followed by injection of 1% Xylocaine with epinephrine. Debridement of the wounds was performed. The wounds were vigorously scrubbed. Once this was completed, the tissue was rearranged and the remaining border was lined up at the oral commissure as well as one-third border with 6-0 nylon suture. Further 6-0 nylon suture was used to repair the multiple wounds to the chin area. A 4-0 chromic suture was used in an inverted fashion to repair the vermilion and mucosal aspect of the lip down to the inferior labial sulcus. A 4-0 chromic suture was also used to repair the gingival labial sulcus wound. The patient did receive 1 gram of Rocephin in the emergency room and was given a prescription for Augmentin 500 mg t.i.d. The patient's father was instructed to watch for signs of infection and to call immediately if any redness, fever or significant swelling occurred. The patient has been instructed to be on a soft diet and was given ice to his lips. He will be followed up in the office next week.

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