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: Arthroscopic Subacromial Decompression - Shoulder

Description: Arthroscopy with arthroscopic subacromial decompression of the left shoulder. Impingement syndrome, left shoulder. Rule out superior labrum anterior and posterior lesion, left shoulder.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Impingement syndrome, left shoulder.
2. Rule out superior labrum anterior and posterior lesion, left shoulder.

POSTOPERATIVE DIAGNOSES: Impingement syndrome, left shoulder.

PROCEDURE PERFORMED: Arthroscopy with arthroscopic subacromial decompression of the left shoulder.

ANESTHESIA: The procedure was done under an interscalene block and subsequent general anesthetic in the modified beachchair position.

SPECIFICATIONS: The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.

HISTORY AND GROSS FINDINGS: This is a 30-year-old white female suffering increasing left shoulder pain for a number of months prior to surgical intervention. She was completely refractory to conservative outpatient therapy. She had subacromial injection, which relieved the majority of her pain. She also had medial bordered scapular pain unrelated directly to the present problem. She had plus minus SLAP lesion testing preoperatively.

Operative findings in the joint included labrum was intact, long head of the biceps intact, laxity of 1+ all around, but clinically intact and without laxity. Subacromially, type-II plus acromion and no evidence of significant rotator cuff tear with scuffing only.

She also had evidence of calcium deposition in the CA ligament and undersurface of the AC joint.

OPERATIVE PROCEDURE: The patient was laid supine upon the operative table. After receiving interscalene block general anesthetic by Anesthesia Department, she was placed in modified beachchair position. She was prepped and draped in the usual sterile manner. Portals were created outside the end, anterior and posterior, posterior and anterior, and subsequently laterally. A full and complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint with the above noted findings.

Attention was then turned to the subacromial region. The scope was placed. A lateral portal was created. Gross bursectomy was carried out. This was done with a 4.2 meniscal shaver as well as a hot Bovie. Calcium deposition mentioned was removed. With the rotator cuff intact, the periosteum was burned off the undersurface of the acromion and the CA ligament released anteriorly. A subacromial decompression sequentially from laterally to medially was then carried out. There was an excellent decompression. Debridement was carried out to the bursa. The portals were ultimately closed with #4-0 after Pain Buster catheter had been placed. Subacromial region was flooded with 0.5% Marcaine at approximately 15 cc or so. Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing. The patient was awoken and transferred to PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair.

Keywords: surgery, impingement syndrome, shoulder, arthroscopic subacromial decompression, beachchair position, subacromial region, arthroscopic, interscalene, arthroscopy, impingement, labrum, acromion, portals, decompression, subacromial,
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