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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Radiofrequency Ablation
Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

Radiologic Exam - Spine
Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.

Records Review - Orthopedic
Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.

Release of A1 Pulley
The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.

Release of A1 Pulley - 1
Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.

Rheumatology Progress Note
Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.

RICE Therapy
A sample note on RICE Therapy

Right Shoulder Hemiarthroplasty
Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease.

Rotator Cuff Repair
Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.

Rotator cuff syndrome - H&P
Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.

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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