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Podiatry Medical Transcription Operative Sample Report


PREOPERATIVE DIAGNOSIS: Ganglion cyst, left lateral aspect of the ankle.

POSTOPERATIVE DIAGNOSIS: Ganglion cyst, left lateral aspect of the ankle.

OPERATION PERFORMED:  Removal of ganglion cyst, left ankle.

SURGEON:  John Doe, MD

ANESTHESIA:  Local 12 mL of 2% lidocaine plain and 0.5% Marcaine plain in a 1:1 mixture.

SPECIMEN:  Ganglion cyst, gross specimen.

TOURNIQUET:  Pneumatic ankle tourniquet, elevated to 250 mmHg on the left ankle.



DESCRIPTION OF OPERATION:  The patient was brought to the OR and placed in supine position on the operating room table. Pneumatic ankle tourniquet was placed on the left ankle and 12 mL of 0.5% Marcaine plain and 2% of lidocaine plain was injected into the left lateral aspect of the ankle.

The left foot was then draped and prepped in normal sterile fashion and the left leg was elevated to exsanguinate the limb. Pneumatic ankle tourniquet was elevated at 250 mmHg. A 20-cm incision was made in the left lateral aspect of the ankle being careful to prevent any damage in the underlying neurovascular structures or preventing any puncturing of the ganglion cyst directly underneath the skin.

Sharp and blunt dissection was used to go down to the level of the peroneus tertius muscle/tendon, which was where the mass was attached. During this time, the mass was punctured and gelatinous material was expressed. The mass was traced down as far distally as possible and tied with #3-0 Vicryl. It was then traced as far proximally as possible and also tied with #3-0 Vicryl. The mass was removed, being careful to prevent any more damage to it and being careful to prevent any damage to any surrounding neurovascular structures, tendons or muscular soft tissue structures in the area. The mass was then removed in toto and sent to pathology as a gross specimen.

Surgical site was then copiously irrigated with normal saline and subcutaneous tissues were reapproximated using Vicryl. A 7-French TLS drain was then placed into the deepest aspect of the surgical site underneath the partially approximated subcutaneous tissue. Skin was then reapproximated using Novafil in a horizontal-type suture fashion. Marcaine was then injected into the surgical site postoperatively and Steri-Strips and Betadine-soaked Adaptic were the start of the dressing, which was completed using Kerlix and an Ace wrap.

The patient returned to the recovery room with neurovascular status intact at digits 1 through 5, left foot, and vital signs stable. The patient was advised to keep the drain in until the followup visit in approximately 1 week with Dr. Doe. To keep the bandage clean, dry, and intact during this time, and recovery vital signs are to be taken.


PREOPERATIVE DIAGNOSIS:  Chronic nonhealing wound, posterior aspect of left leg.

POSTOPERATIVE DIAGNOSIS:  Chronic nonhealing wound, posterior aspect of left leg.

OPERATION PERFORMED:  Excision of chronic wound, posterior aspect of left lower leg with debridement of Achilles tendon and primary closure of wound.



FINDINGS AND DESCRIPTION OF OPERATION:  The patient was taken to the operating room where she was placed on the operating room table in prone position.  At this time, anesthesia was obtained by combination of local infiltration of 50:50 mixture of 2% plain Xylocaine and 0.5% plain Marcaine distributed about the surgical site.  This was supplemented by the sedation supplied by the anesthesia department.  At this time, the left leg was prepped and draped in the usual sterile manner following which the left lower extremity was elevated and exsanguinated with the use of an Esmarch bandage followed by inflation of the calf-level pneumatic tourniquet to 250 mmHg to obtain hemostasis.  At this time, attention was directed to the posterior aspect of the left leg where there was an approximately 5 mm nonhealing inflammatory wound located within the substance of a previous Achilles tendon repair scar.  At this time, two converging elliptical incisions were made surrounding this wound, approximately 5 cm in length.  Following removal of skin wedge, it was noted that there was significant adherence of the skin to the surrounding subcutaneous and tendinous tissues.  With combination of sharp and blunt dissection, these tissues were separated into their natural tissue planes.  Wound culture was taken at this time.  There were found to be several areas of inflammatory tendon damage noted.  This was sharply resected from the tendon.  Of note, there were also remnants of a FiberWire suture from the previous Achilles tendon repair found within the substance of this tendon.  This was also removed from the wound.  At this time, exploration of the wound showed no evidence of abscess or acute infectious process.  However, due to the chronicity of the wound and a previous history of bacterial infection, pulse lavage of the wound was accomplished with 3000 mL of saline solution.  Upon completion of this, the Achilles tendon was retubularized using running suture of 3-0 PDS.  Skin margins were then brought together utilizing simple interrupted sutures of 3-0 Prolene.  Surgical site was then dressed with Xeroform impregnated gauze, 4 x 4s, Kling, and Coban dressing.  Pneumatic tourniquet was deflated after which a well-padded posterior splint in slight plantar flexion was placed on the leg.  The patient tolerated surgery and anesthesia well and was transported to the recovery room with vital signs stable.