Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: ENT - Otolaryngology
Sample Name: Ear Laceration Repair

Description: Repair of left ear laceration deformity Y-V plasty 2 cm. Repair of right ear laceration deformity, complex repair 2 cm.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Bilateral ear laceration deformities.

POSTOPERATIVE DIAGNOSIS: Bilateral ear laceration deformities.

PROCEDURE:
1. Repair of left ear laceration deformity Y-V plasty 2 cm.
2. Repair of right ear laceration deformity, complex repair 2 cm.

ANESTHESIA: 1% Xylocaine, 1:100,000 epinephrine local.

BRIEF CLINICAL NOTE: This patient was brought to the operating room today for the above procedure.

OPERATIVE NOTE: The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped. The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared. The marsupialized epithelialized tracts were pared to raw tissue. They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge. The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching. Bacitracin, Band-Aid was placed. Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges. This was not taken through the edge of the lobe to decrease the risk of notch deformity. The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge. The 5-0 chromic sutures were used in interrupted fashion for this. The patient tolerated the procedure well. Band-Aid and bacitracin were placed. She left the operating room in stable condition.

Keywords: ent - otolaryngology, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair,
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