Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic
Sample Name: Diskectomy & Fusion

Description: Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Degenerative disk disease at L4-L5 and L5-S1.

POSTOPERATIVE DIAGNOSIS: Degenerative disk disease at L4-L5 and L5-S1.

PROCEDURE PERFORMED: Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.

ANESTHESIA: General.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 150 mL.

PROCEDURE IN DETAIL: Patient was prepped and draped in sterile fashion. Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie, and then preperitoneal space was opened. The iliac veins were carefully mobilized medially, and then the L4-L5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by Dr. X, was performed after the adequate exposure was gained, and then after this L4-L5 disk space was fused and the L5-S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed. Diskectomy and fusion, which will be separately dictated by Dr. X, were performed. Once this was completed, all hemostasis was confirmed. The preperitoneal space was reduced. X-ray confirmed adequate positioning and fusion. Then the fascia was closed with #1 Vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 Vicryl subcutaneous tissues and then a 4-0 Monocryl subcuticular stitch, then dressed with Steri-Strips and 4 x 4's. Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities.

Keywords: orthopedic, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion,
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