Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Ophthalmology
Sample Name: Blepharoplasty - Lower Lid

Description: Lower lid blepharoplasty.
(Medical Transcription Sample Report)

The patient was prepped and draped. The lower lids were marked out with a marking pen, especially in the lateral canthus. The lateral canthus was marked out in a convenient wrinkle. The skin in the subciliary incision site was injected with an anesthetic solution of 2% Xylocaine and 1:100,000 epinephrine along with one ampule of Wydase per 60 mL of anesthetic solution.

An orbital block was done. An infraorbital block was also performed with a 25 gauge needle. A skin muscle flap was elevated by sharp dissection down to the orbital rim area. The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp. The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.

The remaining fat was left to fall back into the orbit. This was done in three compartments, the middle, medial and lateral compartments. Fat was removed from all three compartments. Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.

Bleeding was minimal. The patient tolerated the procedure well.

Keywords: ophthalmology, lower lid, wydase, blepharoplasty, infraorbital block, muscle flap, orbital rim area, orbital septum, periorbital fat, subciliary incision, upward gaze, orbital, clamping,
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