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Total Mastectomy Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Multicentric ductal carcinoma in situ of the right breast.

POSTOPERATIVE DIAGNOSIS:  Multicentric ductal carcinoma in situ of the right breast.

PROCEDURE PERFORMED:  Left and right total mastectomy with skin-sparing incision.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

COMPLICATIONS:  None.

INTRAOPERATIVE FINDINGS:  The left breast was excised and oriented with a short suture placed superiorly and a long suture placed laterally as was the right breast.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in a supine position. After induction, she was carefully endotracheally intubated and administered general anesthesia. Her arms were placed on arm boards at less than a right angle to her body and secured. Both breasts as well as the lateral thoraces, shoulders, and neck were carefully prepped and draped in the usual aseptic fashion. Skin-sparing incisions were planned and drawn on the skin with small ellipses at the very edge of the areolar border bilaterally. We began on the left using a 15 blade scalpel. A time-out was called, and the patient's identity as well as the procedure, sites, and sides confirmed before we proceeded. The left breast incision was made with a 15 blade scalpel, then extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. Skin flaps were raised circumferentially in the plane between the investing adipose of the skin and the investing adipose of the breast. Being that the patient was rather thin, there was very little distance between the actual breast tissue itself and the overlying skin, making for a very narrow target throughout the procedure. Skin flaps were raised down to the chest wall in the superior, medial, and inferior positions, and down to the lateral border of the latissimus dorsi muscle laterally. Once this was reached, the breast was taken off the chest wall in a superior to inferior, medial to lateral approach using electrocautery. The anterior fascia investing the pectoralis major muscle was included with the specimen and the breast mobilized laterally. On reaching the lateral border of the pectoralis major muscle, this fascia was also incised. The breast was then taken off the axilla superficially so as to not interrupt the long thoracic or the thoracodorsal neurovascular bundles. Once the breast was excised, it was delivered through the periareolar incision and the tissue oriented. A short suture was placed on the skin ellipse superiorly and a long suture placed on the skin ellipse laterally. This left breast was then passed off the field as specimen for evaluation by pathology. The skin envelope was then inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then irrigated with sterile saline and inspected again. Having obtained excellent hemostasis, a laparotomy sponge soaked in sterile saline was then placed within the skin envelope in order to prevent desiccation. This was then covered with a sterile towel and our attention turned to the contralateral side. Gloves as well as instruments were changed in approaching the right side. Again, the right breast was approached through a skin ellipse as well as drawn on either side of the areolar border. The skin incision was made with a 15 blade scalpel, then extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. Skin flaps were raised circumferentially between the investing adipose of the skin and the investing adipose of the breast. Like the left side, there was very little distance between the actual breast tissue itself and the skin proper. The raising of the skin flaps was complicated by the fact that previous nipple exploration with duct excision had previously taken place as well as sentinel node biopsy within the low axilla. However, this was taken down to the chest wall in the superior, medial, and inferior position, and down to the lateral border of the latissimus dorsi laterally. The breast was then taken off the chest wall, including the anterior fascia investing the pectoralis major muscle. This was done in a superior to inferior and medial to lateral fashion, traveling parallel to the muscle fibers. Once the breast was mobilized laterally, the lateral border of the fascia along the pectoralis major muscle was also incised with electrocautery. The breast tissue was then taken off the axilla superficially, and once excised, was delivered through the periareolar incision. Like the left side, this was then oriented with a short suture placed superiorly on the skin ellipse and a long suture placed laterally on the skin ellipse. This was passed off the field for evaluation by surgical pathology as the right breast. The operative field was then inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then irrigated extensively with sterile saline and inspected again. Having obtained excellent hemostasis, this wound too was packed with sterile saline soaked laparotomy sponge and covered a sterile dry towel. The case was then turned over to Dr. Jane Doe who then proceeded with the tissue expander placements, drain placements, and skin closure. The patient tolerated the procedures well. Sponge, needle, and instrument counts up to this point were not done until the close of the case. Complications up to this point were none. Estimated blood loss up to this point was less than 50 mL.

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