Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

ORIF Small Finger Metacarpal Shaft Fracture Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left small finger with displaced metacarpal shaft fracture.

POSTOPERATIVE DIAGNOSIS:
Left small finger with displaced metacarpal shaft fracture.

OPERATION PERFORMED:
Open reduction and internal fixation of left small finger metacarpal shaft fracture.

SURGEON:  John Doe, MD

ANESTHESIA:  General with regional block.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and positioned supine on the operating table. A time-out was taken at which point the patient's identity, procedure, laterality and surgical plan were reviewed and confirmed. Then, 1 gram of IV cefazolin was administered and general anesthesia was induced. A regional block was placed by the anesthesiologist. A left arm tourniquet was placed and the left upper extremity was then prepped and draped in standard sterile surgical fashion. The planned longitudinal incision was marked out. After exsanguination, the tourniquet was inflated. A skin incision was made and carefully carried down to the subcutaneous tissue. The extensor tendon to the small finger was carefully retracted radially. The periosteum underling the fascial site was opened and dissected radially and ulnarly. The fascial site was cleaned and fascia reduced without significant difficulty. The appropriately-sized 2.0 mm Synthes plate was chosen and affixed to the dorsal ulnar aspect of the metacarpal. Being satisfied with the plate position, the screw holes were filled with 2.0 mm screws with good purchase. Satisfactory reduction and hardware placement were confirmed on fluoroscopy. The wound was then thoroughly irrigated. The interossei and periosteum were repaired over the plate and the dermis was then reapproximated using 4-0 Monocryl suture. The hand was then washed and dried and 10 mL of 0.5% Marcaine with epinephrine was injected into the skin about the incision. A dry sterile dressing was placed followed by a well-padded ulnar gutter splint. The tourniquet was let down with immediate reperfusion to the entire hand. Estimated blood loss was minimal. Sponge, needle and instrument counts were correct and certified x2.

ORIF of Radius and Ulnar Fracture Sample     ORIF of Thumb Intra-articular Base Fracture