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: AC Separation Revision & Hardware Removal

Description: Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Right AC separation.

POSTOPERATIVE DIAGNOSIS: Right AC separation.

PROCEDURES: Removal of the hardware and revision of right AC separation.

ANESTHESIA: General.

BLOOD LOSS: 100 cc.

COMPLICATIONS: None.

FINDINGS: Loose hardware with superior translation of the clavicle implants.

IMPLANTS: Arthrex bioabsorbable tenodesis screws.

SUMMARY: After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.

Final needle and instrument counts were correct.

Keywords: surgery, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware,
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