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: Ruptured Globe Repair - Posterior Sclera

Description: Repair of ruptured globe involving posterior sclera - Sample/Template.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Ruptured globe OX.

POSTOPERATIVE DIAGNOSIS: Ruptured globe OX.

PROCEDURE: Repair of ruptured globe OX.

ANESTHESIA: General

SPECIMENS: None.

COMPLICATIONS: None.

INDICATIONS: This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.

PROCEDURE: The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.

Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.

At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried.

Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.

Keywords: surgery, ruptured globe, ancef, bss, maxitrol ointment, ocuflox, anterior chamber, bleeding, conjunctiva, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, scleral rupture, wire lid speculum, repair of ruptured globe, ruptured, anterior, chamber, globe,
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