Orthopedic (Ortho) Medical Transcription Surgery Sample Reports
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left lower extremity infection.
POSTOPERATIVE DIAGNOSIS: Left lower extremity infection.
OPERATION PERFORMED: Left below-the-knee amputation.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. Under induction of general anesthesia, the patient was placed in the supine position. The incision was made in a fish-mouth type incision. Dissection was carried down the tibial artery and nerves were identified and cut. The tibial artery and vein were tagged and tied with 2-0 tag sutures. The tibia was cut with an anterior chamfer cut. The distal fibula was then cut about 1 cm proximal to the tibia. The posterior tibial artery and vein were then identified and tagged and tied. The tibial nerve was identified, tagged, and cut. The wounds were then closed in a running locking fashion. Prognosis for this patient is dressing changes daily. No x-rays will be needed at first followup visit.
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DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right tibiotalar subluxation.
2. Right ankle retained loose bodies.
3. Right distal tibiofibular plafond injury.
POSTOPERATIVE DIAGNOSES:
1. Right tibiotalar subluxation.
2. Right ankle retained loose bodies.
3. Right distal tibiofibular plafond injury.
OPERATION PERFORMED:
1. Application of spanning external fixator to reduce tibiotalar subluxation.
2. Right ankle arthroscopy and debridement of loose bodies.
3. Open reduction and internal fixation with arthroscopic-assisted tibial plafond fixation.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal.
FINDINGS AND OPERATIVE PROCEDURE: The patient was taken to the operating room and underwent induction of general anesthesia. The patient was placed in the supine position. Dissection was then carried down using a transfixation pin through the proximal tibia and transfixation pins through the calcaneus and distraction was used to release tibiotalar subluxation. Next, ankle arthroscopy was then performed with debridement with a 3 mm shaver as well as ankle arthroscopy was then performed to remove all loose bodies within the ankle joint.
Next, arthroscopic-assisted open reduction and internal fixation of the distal tibial plafond was then performed using a series of 0.062 K wires and 2 mm K-wires to reduce the posterior impaction. This was then reduced and held in place. Cables were then flipped across in order to reduce the posterior malleolus. Secondary 3.5 cortical screws were then applied across medial and lateral through the flip anchor.
Next, medial malleolar fixation was then performed with two medial malleolar screws, inserting and reducing the medial malleolar articular surface. Through direct arthroscopic visualization, 3.5 cortical screws were then inserted across the fracture site in order to reduce the medial malleolus.
Next, we then released our traction and reduced our fibula using a 2.4 K-wire, followed by insertion of a 3.5 x 15 cm fibular nail. Reduction was noted to be anatomic in all planes. The distraction external fixator was removed.
Orthopedic Operative Samples #1
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DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left radiocarpal subluxation.
2. Left distal radius fracture.
POSTOPERATIVE DIAGNOSES:
1. Left radiocarpal subluxation.
2. Left distal radius fracture.
OPERATION PERFORMED:
1. Application of spanning external fixator to reduce the radiocarpal subluxation.
2. Open reduction and internal fixation of left distal radius fracture with a volar bearing plate.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. Under endotracheal general anesthesia, he was placed in the supine position. The left distal radius was prepped and draped in the usual fashion. Radiocarpal subluxation was corrected with a spanning external fixator using 3.0 mm pins in the proximal radius and in the second and index metacarpal.
Distraction was then used to reduce radiocarpal subluxation. Next, dissection was then carried down through FCR tendon sheath, through the pronator quadratus and subsequently subperiosteal dissection. Intra-articular reduction was then achieved, held primarily with 0.062 K-wires. A volar bearing plate was then applied and secured with 3.2 and 2.3 screws respectively. Reduction was noted to be acceptable and anatomic in all planes.
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DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left midshaft radius fracture.
POSTOPERATIVE DIAGNOSIS: Left midshaft radius fracture.
OPERATION PERFORMED: Open reduction and internal fixation of left midshaft radius fracture.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. Under induction of general anesthesia, the patient was placed in the supine position. A 3.5 drill bit was used to create a starting portal at the dorsal ulnar aspect of the distal radius as well as over the radial styloid. A 2.5 Nancy nail was then inserted across the fracture site as well as a 2.0 mm Nancy nail. Reduction was noted to be anatomic on both the AP and lateral planes.
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DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right elbow fracture.
POSTOPERATIVE DIAGNOSIS: Right elbow fracture.
OPERATION PERFORMED: Closed reduction of right distal humerus fracture and splinting.
DESCRIPTION OF PROCEDURE: Under conscious sedation provided by the emergency room staff, a propofol bolus was given and mask ventilation was obtained after appropriate preoxygenation of the patient. Once she was appropriately sedated, gentle longitudinal traction was applied to the distal elbow, and anterior angulated force was applied on the olecranon to reduce the fracture. A long arm fiberglass splint was then placed in the reduced position. Postprocedural x-rays were obtained, AP and lateral views, which did show continued intra-articular distal radius fracture but improved angulation. No significant compromise on the anterior soft tissues. The patient tolerated this procedure without complications. She was to be admitted overnight for open reduction and internal fixation in the a.m.
Orthopedic Operative Samples #2
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DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left proximal humerus fracture.
2. Left tarsometatarsal dislocation of the foot.
POSTOPERATIVE DIAGNOSES:
1. Left proximal humerus fracture.
2. Left tarsometatarsal dislocation of the foot.
OPERATION PERFORMED:
1. Intramedullary nailing left proximal humerus fracture.
2. Open reduction internal fixation left tarsometatarsal joint.
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. Anesthesia administered. After adequate anesthesia, the patient’s left humerus fracture was addressed. Prep and drape was performed. The patient was positioned in a captain’s chair in a beach-chair position. The prep and drape accomplished, adhesive drapes utilized to isolate the axilla.
The patient’s fracture was varus with greater tuberosity fracture. Drilling was accomplished. The varus position was addressed with two K-wires placed. This also served as a reference site to the axis of the humerus. Following this, the nail entry site was made. Incision was made in line with the lateral aspect of the humeral head, central and sagittal plane, and incision was carried down sharply through skin and subcutaneous tissues. Drilling accomplished followed by over reaming. A guidewire was then passed across followed by passage of the nail. The nail was set and locked with the oblique inferior screw first. A good impaction was accomplished followed by screw placement. The screws were then directed from posteroanterior with head purchase. This also passed through the tuberosity.
The patient’s wounds then approximated, soft dressings applied.
Internal fixation tarsometatarsal joint: The patient’s left tarsometatarsal joint was then addressed. The alignment was confirmed by C-arm image followed by drilling, over drilling, and placement of two interfragmentary screws. The patient had good confirmation, both in frontal and sagittal plane views. The patient’s wounds approximated, soft dressings applied, and the patient transferred to recovery area.
