Report Example on Operation: Excisional Biopsy

Anesthesia: local block with (.5%/0.5 percent/.5 percent/0.5%) marcainePre-Operative Diagnosis: mass right forearm

Post-Operative Diagnosis: mass right forearm probably fat necrosis secondary to trauma

Operation Started: 12.05 pm

Operation Ended: 12.55 pm

CLINICAL HISTORY

Mathew, a 52-year-old patient, was diagnosed with a mass in the right forearm which he testified had been present for the past three years. The patient began feeling a lump-like swelling in the right arm which was painless. On further interrogation, the patient denied any recent broadening of the lump. But, for the past one year, the patient reported that he had a continuing increase in numbness at the index finger and middle of the ipsilateral arm. There was no reported history of disturbance. Also, both medical and family history were unremarkable.

Physical examination showed a profound oval mass on the right forearm on the medial side. The lumps diameter was ascertained to be approximately 4 cm. Neurological examination was normal. Routine laboratory analysis comprised of total blood cell count, erythrocyte sedimentation rate, serum chemistries and C-reactive protein. All these tests were found to be within reasonable limits. The patient was advised to undergo surgery to remove the lump.

PROCEDURE

The operation team wheeled the patient into the operating room, prepped and draped in the supine position after the induction of adequate anesthesia. Then the patient's arm was held elevated, and a tourniquet which was placed high on the arm was elevated to (250/two hundred fifty) mmHg. Next attention was directed to the volar ulnar forearm where an incision approximately (one/1) inch long was made and carried into the subcutaneous tissues. A sharp dissection was made using knife scissors. The spreading reveal a mass which appeared to be fat. Following this finding, the fat was removed in toto. The surgeon team explored the area surrounding the right foreman, and no further abnormalities were found. The mass was then sent to the pathology whereby the patients wound was copiously treated with dilute betadine solution. Then the skin was then closed in plastic fashion using (four zero/4-0) prolene interrupted vertical mattress sutures. Later the team washed the patients wound with dilute betadine solution and dressed with betadine ointment and sterile bulky dressing. The surgical procedure completed the whole process. Apart from this process, the entire process went very smoothly with excellent cooperation and toleration from the patient. The amount of blood loss was very minimal thus the patient needed no blood transfusion

OPERATION FINDINGS

A sharp dissection was made on the arm using knife scissors whereby a spreading revealed a mass which resembled fat in the form of a ball. The ball of fat was then removed. On further investigation, no more abnormalities were observed. The operation was a success as the patient left the room with their medical condition solved.

FOLLOW UP CARE

The patient was consequently discharged the same day with a comprehensive pre-prepared set of instructions for home care. The guidelines were explicitly designed for patients with right arm mass. A packet of supplies for wound care was provided to aid in the home care procedures. The patient was advised to return for suture removal and would check after seven days.

Signature:

Joan R. Richards, Surgeon