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 Rotator Cuff Repair

Description: Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.
(Medical Transcription Sample Report)

PROCEDURE: Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.

PATIENT PROFILE: This is a 42-year-old female. Refer to note in patient chart for documentation of history and physical. Due to the nature of the patient's increasing pain, surgery is recommended. The alternatives, risks and benefits of surgery were discussed with the patient. The patient verbalized understanding of the risks as well as the alternatives to surgery. The patient wished to proceed with operative intervention. A signed and witnessed informed consent was placed on the chart. Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.

PRE-OP DIAGNOSIS: Acute complete tear of the supraspinatus, Shoulder impingement syndrome.

POST-OP DIAGNOSIS: Acute complete tear of the supraspinatus, Shoulder impingement syndrome.

ANESTHESIA: General - Endotracheal.

FINDINGS:
ACROMION:
1. There was a medium-sized (5 - 10 mm) anterior acromial spur.
2. The subacromial bursa was inflamed.
3. The subacromial bursa was thickened.
4. There was thickening of the coracoacromial ligament.
LIGAMENTS / CAPSULE: Joint capsule within normal limits.
LABRUM: The labrum is within normal limits.
ROTATOR CUFF: Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral. Muscles and Tendons: The biceps tendon is within normal limits.
JOINT: Normal appearance of the glenoid and humeral surfaces.

DESCRIPTION OF PROCEDURE:
PATIENT POSITIONING: Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table. All body parts were well padded and protected to make sure there were no pressure points. Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.
INCISION TYPE:
1. Scope Ports: Anterior Portal.
2. Scope Ports: Posterior Portal.
3. Scope Ports: Accessory Anterior Portal.
INSTRUMENTS AND METHODS:
1. The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.
2. The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.
3. The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.
4. The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr. Approximately 5 mm of bone was removed. The coracoacromial ligament was released with the bony resection. The shoulder joint was thoroughly irrigated.
5. The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.
6. The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures). The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.
7. The repair was stable to palpation with the probe and watertight.
8. The arthroscope and instruments were removed from the shoulder.
PATHOLOGY SPECIMEN: No pathology specimens.
WOUND CLOSURE: The joint was thoroughly irrigated with 7 L of sterile saline. The portal sites were infiltrated with 1% Xylocaine. The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.
DRAINS / DRESSING: Applied sterile dressing including gauze, iodoform gauze and Elastoplast.
SPONGE / INSTRUMENT / NEEDLE COUNTS: Final counts were correct.
INTRAOPERATIVE MEDICATIONS: No transfusions; minimal blood loss.
CAST / IMMOBILIZATION: The extremity was immobilized in a shoulder immobilizer.
PATIENT TO RECOVERY ROOM: The patient tolerated the procedure well, and was brought to the recovery room in good condition.

COMPLICATIONS: No Immediate Complications.

POST-OP PLAN:
DISCHARGE ORDERS:
DISPOSITION: Discharge patient to home upon release from Post-Op Recovery.
MEDICATIONS: Hydrocodone/Acetaminophen (Vicodin 5/500) 1-2 tabs PO q 6 hr PRN.
ACTIVITY: The patient may shower as tolerated.
FOLLOW-UP: Appointment to Orthopedics Clinic within several days.

CPT4 CODE(S):
29827, RT, Arthroscopy, shoulder, surgical; with rotator cuff repair.
29826, RT, Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release.

ICD9 CODE(S):
840.6 Supraspinatus (muscle/tendon) sprain.
726.2, Other affections of shoulder region, not elsewhere classified.

Keywords: surgery, subacromial decompression, arthroscopic rotator cuff repair, supraspinatus, impingement syndrome, tear, subacromial bursa, rotator cuff repair, arthroscopic rotator, biceps tendon, cuff repair, rotator cuff, arthroscopic, shoulder, arthroscopy, decompression, bursa, rotator, subacromial, cuff,
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