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: Phacoemulsification & Cataract Extraction - 3

Description: Cataract, right eye. Phacoemulsification with intraocular lens insertion, right eye. A wire lid speculum was inserted to keep the eye open and the eye rotated downward.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Cataract, right eye.

POSTOPERATIVE DIAGNOSIS: Cataract, right eye.

TITLE OF OPERATION: Phacoemulsification with intraocular lens insertion, right eye.

ANESTHESIA: Retrobulbar block.

COMPLICATIONS: None.

PROCEDURE IN DETAIL: The patient was brought to the operating room where retrobulbar anesthesia was induced. The patient was then prepped and draped using standard procedure. A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12. The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome. The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed. The phacoemulsification was then instilled in the eye and a linear incision made in the lens. The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip. The remaining cortex was removed with an I&A. The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome. The folding posterior chamber lens was then inserted in the capsular bag and rotated into position. The remaining viscoelastic was removed from the eye with the I&A. The wound was checked for watertightness and found to be watertight. Tobramycin drops were instilled in the eye and a shield placed over it. The patient tolerated the procedure well.

Keywords: ophthalmology, tobramycin, limbal, lid speculum, intraocular lens, capsular bag, eye, phacoemulsification, lens, intraocular,
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