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Mastectomy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right breast carcinoma.

POSTOPERATIVE DIAGNOSIS:
Right breast carcinoma.

OPERATION PERFORMED:
1.  Right modified radical mastectomy.
2.  Sentinel node biopsy.
3.  Left simple mastectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic female who presents with a right breast carcinoma. After weighing her options, she opted for right breast modified radical mastectomy with sentinel node biopsy, axillary node dissection and prophylactic left simple mastectomy. The risks and benefits of the procedure were explained to the patient. Informed consent was obtained.

DESCRIPTION OF OPERATION:  The patient was taken to the operating suite and placed in the supine position. General anesthesia was given by the anesthesiology department. Bilateral breasts and arms were prepped and draped in the normal sterile fashion.

The left simple mastectomy was performed first. An elliptical incision was made incorporating the nipple-areolar complex. Dissection was carried down through the subdermal tissues using cutting. Skin flaps were then created. Dissection was carried superiorly to the level of the clavicle, medially to the lateral portion of sternomastoid, inferiorly to the superior portion of the rectus muscle, and laterally to latissimus dorsi muscle. A subfascial dissection was then performed, and the specimen was tagged laterally. The specimen was then submitted to pathology.

The wound was copiously irrigated with water. Bleeding on the pectoralis muscle was controlled with electrocautery. The wound was irrigated and no active bleeding was noted. The skin was injected with Marcaine-lidocaine solution. A drain was brought in through a separate stab incision. The drain was secured to the skin using 2-0 nylon. The wound was closed in 2-layer fashion and 3-0 Vicryl was used to approximate the subdermal areas and 4-0 Vicryl was used to close the skin in a running subcuticular manner.

The operator then changed gown and gloves and a whole new setup was then used for the right side. Lymphazurin was injected in the retroareolar area. An elliptical incision was made incorporating the nipple-areolar complex and previous biopsy site. Dissection was carried down through the subdermal tissues using cutting. Skin flaps were then created. Dissection was carried superiorly to the level of the clavicle, medially to the lateral portion of sternomastoid, inferiorly to the superior portion of the rectus muscle, and laterally to latissimus dorsi muscle. A subfascial dissection was then performed and the breast was injected laterally.

The clavipectoral fascia was incised. A clear blue node was identified. This was submitted for touch prep and a touch prep was negative. This was the sentinel node. At this point, the wound was copiously irrigated with water. Bleeding was controlled with electrocautery. The wound was irrigated and no active bleeding was noted. Two #10 JP drains were brought in through a separate stab incision. The drains were sutured to the skin using 2-0 nylon, one drain was placed in the axilla and one was placed in the pectoralis muscle. The wound was closed in a 2-layer fashion and 3-0 Vicryl was used to approximate the subdermal areas and 4-0 Vicryl was used to close the skin in a running subcuticular manner. Steri-Strips and sterile dressings were then applied. The patient was then sent to the recovery room in satisfactory condition.