Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Ophthalmology
Sample Name: Blepharon & Entropion Repair

Description: Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Entropion, left upper lid.
2. Entropion and some blepharon, right lower lid.

TITLE OF OPERATION:
1. Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.
2. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.

PROCEDURE IN DETAIL: The patient was brought to the operating room and prepped and draped in the usual fashion. The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.

The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness. The graft was placed in saline and a 4 x 4 was placed over the lower lid.

Attention was then drawn to the left upper lid and the operating microscope was found to place. An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised. Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.

Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade. Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery. An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.

The graft was in good position and everything was satisfactory at the end of procedure. Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied. No patch was applied to the left eye. The patient tolerated the procedure well and was sent to recovery room in good condition.

Keywords: ophthalmology, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane,
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