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: Phacoemulsification Of Cataract - 2

Description: Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Cataract, right eye.

POSTOPERATIVE DIAGNOSIS: Cataract, right eye.

PROCEDURE: Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.

ANESTHESIA: Topical.

COMPLICATIONS: None.

PROCEDURE IN DETAIL: The patient was identified. The operative eye was treated with tetracaine 1% topically in the preoperative holding area. The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.

Attention was turned to the left/right eye. The lashes were tapped using Steri-Strips to prevent blinking. A lid speculum was placed to prevent lid closure. Anesthesia was verified. Then, a 3.5-mm groove was created with a diamond blade temporarily. This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane. A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat. A paracentesis was made. A round capsulorrhexis was performed. The anterior capsular flap was removed. Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique. The irrigating-aspirating machine was used to clear residual cortex. The Provisc was instilled. An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified. The viscoelastic was removed. Intraocular lens remained well centered. The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal. The anterior chamber remained deep, and there was no wound leak. The patient tolerated the procedure well. The eye was dressed with Maxitrol ointment. A tight patch and Fox shield were placed. The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.

Keywords: surgery, cataract, posterior chamber, intraocular lens, hydrodelineation, phacoemulsification of cataract, phacoemulsification, lens, anterior, chamber, eye, 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