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: Synovectomy - Partial

Description: Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Septic left total knee arthroplasty.

POSTOPERATIVE DIAGNOSIS: Septic left total knee arthroplasty.

OPERATION PERFORMED: Arthroscopic irrigation and debridement of same with partial synovectomy.

ANESTHESIA: LMA.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

DRAINS: None.

INDICATIONS: The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection. The patient' knee was aspirated in the office and cultures were positive for Escherichia coli. She presents for operative therapy.

DESCRIPTION OF OPERATION: After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position. The left upper extremity was prepped and draped without a tourniquet. The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created. The arthroscopy was inserted and a complete diagnostic was performed. Arthroscopic pictures were taken throughout the procedure. The knee was copiously irrigated with 9 L of irrigant. A partial synovectomy was performed in all compartments. Minimal amount of polyethylene wear was noted. The total knee components were identified arthroscopically for future revision surgery. The knee was then drained and the arthroscopic instruments were removed. The portals were closed with 4-0 nylon and local anesthetic was injected. A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well.

Keywords: surgery, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy,
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