Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Ophthalmology
Sample Name: Vitrectomy - 2

Description: Pars plana vitrectomy, membrane peel, 23-gauge, right eye.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: Epiretinal membrane, right eye. CME, right eye.

POSTOPERATIVE DIAGNOSES: Epiretinal membrane, right eye. CME, right eye.

PROCEDURES: Pars plana vitrectomy, membrane peel, 23-gauge, right eye.

PREOPERATIVE FINDINGS: The patient had epiretinal membrane causing cystoid macular edema. Options were discussed with the patient stressing that the visual outcome was guarded. Especially since this membrane was of chronic duration there is no guarantee of visual outcome.

DESCRIPTION OF PROCEDURE: The patient was wheeled to the OR table. Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified. Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified. The fluid was run. Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock. Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety. There were no complications. DVT precautions were in place. I, as attending, was present in the entire case.

Keywords: ophthalmology, epiretinal membrane, pars plana vitrectomy, membrane peel, macular edema, cystoid, eye, retrobulbar, epiretinal, vitrectomy, membrane,
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