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: Keller Bunionectomy

Description: Procedure note on Keller Bunionectomy
(Medical Transcription Sample Report)

PROCEDURE: Keller Bunionectomy.

For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.

This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.

Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. The incision was medial to and parallel to the extensor hallucis longus tendon. The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.

Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp. The surgical site was then flushed with saline. The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.

Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion. Site was dressed with a light compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted.

ANESTHESIA: local.

HEMOSTASIS: Accomplished with pinpoint electrocoagulation.

ESTIMATED BLOOD LOSS: 10 cc.

MATERIALS: None.

INJECTABLES: Agent used for local anesthesia was Lidocaine 2% without epi.

PATHOLOGY: Sent no specimen.

DRESSINGS: Site was dressed with a light compressive dressing.

CONDITION: Patient tolerated procedure and anesthesia well. Vital signs stable. Vascular status intact to all digits. Patient recovered in the operating room.

SCHEDULING: Return to clinic in 2 week (s).

Keywords: surgery, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy,
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