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: YAG Laser Capsulotomy

Description: Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Visually significant posterior capsule opacity, right eye.

POSTOPERATIVE DIAGNOSIS: Visually significant posterior capsule opacity, right eye.

OPERATIVE PROCEDURES: YAG laser posterior capsulotomy, right eye.

ANESTHESIA: Topical anesthesia using tetracaine ophthalmic drops.

INDICATIONS FOR SURGERY: This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.

DESCRIPTION OF PROCEDURE: The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.

Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions.

Keywords: surgery, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia,
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