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: Radioactive Plaque - Removal

Description: Radioactive plaque macular edema. Removal of radioactive plaque, right eye with lateral canthotomy. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Radioactive plaque macular edema.

POSTOPERATIVE DIAGNOSIS: Radioactive plaque macular edema.

TITLE OF OPERATION: Removal of radioactive plaque, right eye with lateral canthotomy.

OPERATIVE PROCEDURE IN DETAIL: The patient was prepped and draped in the usual manner for a local eye procedure. Then a retrobulbar injection of 2% Xylocaine was performed. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed. Next, the plaque was identified and the two scleral sutures were removed. The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture. The fundus was inspected with direct ophthalmoscopy. An eye patch was applied following Neosporin solution irrigation. The patient was sent to the recovery room in good condition. A lateral canthotomy had been done.

Keywords: surgery, conjunctiva, eye patch, ophthalmoscopy, radioactive plaque, traction, suture, eye, radioactive, plaque,
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Transcribed Medical Transcription Sample Reports and Examples