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: Cataract Extraction - 2

Description: Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Cataract, left eye.

POSTOPERATIVE DIAGNOSIS: Cataract, left eye.

PROCEDURE PERFORMED: Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.

ANESTHESIA: Topical.

COMPLICATIONS: None.

PROCEDURE: After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion. A speculum was inserted, and the microscope was moved into position.

A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber. It was then filled with viscoelastic. A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.

A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis. The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision. The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees. The posterior capsule was vacuumed; it was clear and intact.

The capsular bag and the anterior chamber were filled with viscoelastic. A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag. The trailing loop was placed inside the bag. The viscoelastic was removed with the irrigation-aspiration handpiece. The lens centered well. A single 10-0 nylon suture was placed to close the wound. It was checked and ascertained to be watertight. Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally. Dexacidin ointment was placed in the eye, and the procedure was terminated.

The procedure was well tolerated by the patient who was returned to the recovery room in good condition.

Keywords: surgery, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,
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