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: Vitrectomy - 1

Description: Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Vitreous hemorrhage and retinal detachment, right eye.

POSTOPERATIVE DIAGNOSIS: Vitreous hemorrhage and retinal detachment, right eye.

NAME OF PROCEDURE: Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.

ANESTHESIA: Local with standby.

PROCEDURE: The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion. As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery. A wire lid speculum was inserted. Three modified sclerotomies were selected at 9, 10, and 1 o'clock. At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture. The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun. Initially formed core vitrectomy was performed and formed anterior vitreous was removed. After this was completed, attention was placed in the posterior segment. Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted. These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata. After all the vitreous had been removed and the membranes released, the retina was completely mobilized. Total fluid-air exchange was carried out with complete settling of the retina. Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery. Good reaction was achieved. The eye was inspected with an indirect ophthalmoscope. The retina was noted to be completely attached. The instruments were removed from the eye. The sclerotomy sites were closed with #7-0 Vicryl suture. The infusion line was removed from the eye and tied with a #7-0 Vicryl suture. The conjunctivae and Tenon's were closed with #6-0 plain gut suture. A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place. The patient left the operating room in a good condition.

Keywords: surgery, vitreous hemorrhage, retinal detachment, combined closed vitrectomy, vitrectomy, membrane peeling, fluid-air exchange, endolaser, vitrectomy with membrane peeling, membrane, peeling, hemorrhage, detachment, vicryl, eye, retinal,
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