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: Closed Reduction - 2

Description: Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Left distal both-bone forearm fracture.

POSTOPERATIVE DIAGNOSIS: Left distal both-bone forearm fracture.

PROCEDURE: Closed reduction with splint application with use of image intensifier.

INDICATIONS: Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the emergency department revealed both-bone forearm fracture. Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction. After discussion with parents, verbal and written consent was obtained.

DESCRIPTION OF PROCEDURE: The patient was induced with propofol for conscious sedation via the emergency department staff. After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture. Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier. The patient was aroused from anesthesia and tolerated the procedure well. Post-reduction plain films revealed some anterior displacement of the distal fragment. At this time, it was determined this fracture proved to be unstable.

DISPOSITION: After review of the reduction films, it appears that there is some element of fracture causing displacement. We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.


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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