Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic
Sample Name: Olecranon Bursa - Excision

Description: Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Acute infected olecranon bursitis, left elbow.

POSTOPERATIVE DIAGNOSIS: Infection, left olecranon bursitis.

PROCEDURE PERFORMED:
1. Incision and drainage, left elbow.
2. Excision of the olecranon bursa, left elbow.

ANESTHESIA: Local with sedation.

COMPLICATIONS: None.

NEEDLE AND SPONGE COUNT: Correct.

SPECIMENS: Excised bursa and culture specimens sent to the microbiology.

INDICATION: The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage. He was then scheduled for I&D and excision of the bursa. Risks and benefits were discussed. No guarantees were made or implied.

PROCEDURE: The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine. The left upper extremity was prepped and draped in standard sterile fashion. On examination of the left elbow, there was presence of thickening of the bursal sac. There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted. An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin. The incision was carried proximally and distally. The olecranon bursa was significantly thickened and scarred. Excision of the olecranon bursa was performed. There was significant evidence of thickening of the bursa with some evidence of adhesions. Satisfactory olecranon bursectomy was performed. The wound margins were debrided. The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution. There was no evidence of a loose body. There was no bleeding or drainage. After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion. The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing. Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias. The patient tolerated the procedure very well. He was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noticed.

Keywords: orthopedic, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa,
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