Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic

The branch of surgery and medicine concerned with the correction or reconstruction of skeletal and spinal deformities.

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Lumbar Laminectomy
Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.

Lumbar Laminectomy & Discectomy
Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.

Lumbar Laminotomy & Discectomy
Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.

Lumbar Puncture - 2
Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.

Lumbar Radiculopathy - Consult
Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.

Lumbar Re-exploration
Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.

Lumbar Spine HNP - Consult
Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.

McBride Bunionectomy & Wedge Osteotomy
Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.

Medial Branch Rhizotomy
Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

Meniscoplasty & Chondroplasty
Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee. Patellar chondroplasty. Lateral femoral chondroplasty. Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,

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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