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: Anterior Cruciate Ligament Reconstruction

Description: Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Anterior cruciate ligament rupture.

POSTOPERATIVE DIAGNOSES:
1. Anterior cruciate ligament rupture.
2. Medial meniscal tear.
3. Medial femoral chondromalacia.
4. Intraarticular loose bodies.

PROCEDURE PERFORMED:
1. Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.
2. Removal of loose bodies.
3. Medial femoral chondroplasty.
4. Medial meniscoplasty.

OPERATIVE PROCEDURE: The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia. Following this, the knee was sterilely prepped and draped as discussed for this procedure. The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region. After the notch was identified, then ACL was confirmed and ruptured. There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface. The snare was smoothed out. Entire area was thoroughly irrigated. Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage. The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing. There were multiple loose bodies noted in the knee and these were then __________ and then removed. The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed. The knee was taken through a full range of motion without any impingement. An Endobutton was used for proximal fixation. Distal fixation was obtained with an independent screw and a staple. The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.


Keywords: orthopedic, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial,
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