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: Rectus Recession

Description: Bilateral rectus recession with the microscopic control, 8 mm, both eyes.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Congenital bilateral esotropia, 42 prism diopters.

PROCEDURE: Bilateral rectus recession with the microscopic control, 8 mm, both eyes.

POSTOPERATIVE DIAGNOSIS: Congenital bilateral esotropia, 42 prism diopters.

COMPLICATIONS: None.

PROCEDURE IN DETAIL: The patient was taken to the Surgery Room and placed in the supine position. The general anesthesia was achieved with intubation with no problems. Both eyes were prepped and draped in usual manner. The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape. The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem. The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position. Inferior fornix conjunctival incision was made and Tenons capsule buttonholed. The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook. The Tenons capsule was buttonholed. The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle. __________ extension of the muscle was excised. The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders. The muscle was disinserted from original insertion. The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion. The suture was pulled, tied, and cut. The muscle was in good position. The conjunctiva was closed with 7-0 Vicryl suture in running fashion. The suture was pulled, tied, and cut. The eye speculum was taken out.

Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion. The suture was pulled, tied and cut. The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut. TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition. To be seen in the office in 1 week.

Keywords: ophthalmology, congenital bilateral esotropia, esotropia, tenons capsule, rectus muscle, bilateral rectus recession, rectus recession, eye speculum, muscle hook, eyes, muscle, rectus,
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