Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Debridements

Description: Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.

POSTOPERATIVE DIAGNOSIS: Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.

PROCEDURE: Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.

ANESTHESIA: General.

COMPLICATIONS: None.

DESCRIPTION OF PROCEDURE: The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field. The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin). The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34. With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments. Muscle in these compartments was contractile. Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment. The lateral compartment appeared contractile. The anterior compartment appeared necrotic for most of the muscle in the compartments. What appeared viable was left intact. A vacuum-assisted closure system was utilized on each fasciotomy wound. Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there. This was included in the VAC seal, as well as the traumatic wound. A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded. He tolerated the procedure well, was taken to the recovery room in good condition.

Keywords: surgery, left lower extremity, debridement of wound, fasciotomies, debridement of muscle, vacuum-assisted closure systems, status post motorcycle accident, vacuum assisted closure systems, vacuum assisted closure, assisted closure systems, wound fasciotomies, fasciotomies debridement, vacuum assisted, closure systems, lower extremity, lateral compartments, anterior compartment, fasciotomy wounds, traumatic wound, wound, anterior, polytrauma, motorcycle, accident, contractile, vacuum, debridements, traumatic, muscle, fasciotomy, compartment,
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