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: Closure of Complex Lacerations

Description: Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Multiple complex lacerations of the periorbital area.

POSTOPERATIVE DIAGNOSIS: Multiple complex lacerations of the periorbital area.

PROCEDURE PERFORMED: Closure of multiple complex lacerations.

ANESTHESIA: Local 1% with epinephrine.

ESTIMATED BLOOD LOSS: Minimal.

SPECIMEN: None.

COMPLICATIONS: None.

HISTORY: The patient is a 19-year-old Caucasian male who presented status post a bicycle versus MVA. The patient obtained multiple complex lacerations of the right periorbital area.

PROCEDURE: Informed consent was properly obtained from the patient and he was placed in a 45-degree angle. Topical viscous lidocaine was applied for pain management and then 1% epinephrine was injected into the periorbital area for anesthetic effect. A #5-0 Vicryl suture was used to close the deep layers and then #6-0 Prolene was used in interrupted fashion for superficial closure. The patient was instructed to take Keflex antibiotic for 10 days. He was also instructed and given prescription for erythromycin ophthalmic ointment to be applied to the periorbital areas t.i.d. The patient is to ice the area and to follow up in one week for suture removal. The patient tolerated the procedure well and he was discharged from the Emergency Room in stable condition.

Keywords: surgery, vicryl suture, complex lacerations, epinephrine, closure, periorbital, lacerations,
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