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: Escharotomy

Description: Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.

POSTOPERATIVE DIAGNOSES: 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.

PROCEDURES PERFORMED:
1. Lateral escharotomy of right upper arm burn eschar.
2. Medial escharotomy of left upper extremity burns and eschar.

ANESTHESIA: Propofol and Versed.

INDICATIONS FOR PROCEDURE: The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax. The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity. The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity. It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.

DESCRIPTION OF PROCEDURE: After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position. An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity. Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue. The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity. All dermal bridging was taken down and was opened without any excessive bleeding. Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity. Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue. All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down. At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer. Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix. The patient tolerated the procedure well, and there were no adverse events during or after the procedure.

Keywords: surgery, lateral escharotomy, medial escharotomy, eschar, anterior thorax, underlying subcutaneous tissue, bilateral upper extremities, impending compartment syndrome, arm burn, extremity burns, humeral head, burn eschar, compartment syndrome, escharotomy, humeral, burns,
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