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: Paraphimosis

Description: Reduction of paraphimosis.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Phimosis.

POSTOPERATIVE DIAGNOSIS: Phimosis.

PROCEDURE: Reduction of paraphimosis.

ANESTHESIA: General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.

FLUIDS RECEIVED: 100 mL.

SPECIMENS: No tissues sent to pathology.

COUNTS: Sponge and needle counts were not necessary.

TUBES/DRAINS: No tubes or drains were used.

FINDINGS: Paraphimosis with moderate swelling.

INDICATIONS FOR OPERATION: The patient is a 15-year-old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution. When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis. The plan is for reduction.

DESCRIPTION OF OPERATION: The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis. Using Betadine and alcohol cleanse, we then did a dorsal penile block and a ring block by surgeon with 0.25% Marcaine, 20 mL were given. He did quite well after the procedure and was transferred to the recovery room in stable condition.

Keywords: surgery, dorsal penile block, reduction of paraphimosis, penile block, phimosis, paraphimosis,
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