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 - 5

Description: Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Cataract, right eye.

POSTOPERATIVE DIAGNOSIS: Cataract, right eye.

PROCEDURE PERFORMED: Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used, * diopters, #*.

ANESTHESIA: Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.

COMPLICATIONS: None.

PROCEDURE: Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling. The patient understood the risks clearly and wished to proceed.

The patient was brought into the operating suite after being given dilating drops. Topical 4% lidocaine drops were used. The patient was prepped and draped in the normal sterile fashion. A lid speculum was placed into the right eye. Paracentesis was made at the infratemporal quadrant. This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters. This was exchanged for Viscoat solution. Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus. This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade. Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps. Balanced salt solution was used to hydrodissect the nucleus. Nuclear material was removed via phacoemulsification with divide-and-conquer technique. The residual cortex was removed via irrigation and aspiration. The capsular bag was then filled with Provisc solution. The wound was slightly enlarged. The lens was folded and inserted into the capsular bag.

Residual Provisc solution was irrigated out of the eye. The wound was stromally hydrated and noted to be completely self-sealing.

At the end of the case, the posterior capsule was intact. The lens was well centered in the capsular bag. The anterior chamber was deep. The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly. Maxitrol ointment was placed into the eye. The eye was patched with a shield.

The patient was transported to the recovery room in stable condition to follow up the following morning.

Keywords: ophthalmology, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, 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