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

Description: Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Vitreous hemorrhage, right eye.

POSTOPERATIVE DIAGNOSIS: Vitreous hemorrhage, right eye.

PROCEDURE: Vitrectomy, right eye.

PROCEDURE IN DETAIL: The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia. Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus. MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture. Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed. All strands of significance were removed. Tractional detachment foci were apparent posteriorly along the temporal arcades. Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control. Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control. The intraocular pressure was within the normal range. The globe was irrigated with a topical antibiotic. The MVR incisions were closed with 7-0 Vicryl. No further manipulations were necessary. The conjunctiva was closed with 6-0 plain catgut. An eye patch was applied and the patient was sent to the recovery area in good condition.

Keywords: ophthalmology, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva,
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