Medical Specialty:
Orthopedic
Sample Name: Achilles Tendon Repair
Description: Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Achilles tendon rupture, left lower extremity.
POSTOPERATIVE DIAGNOSIS: Achilles tendon rupture, left lower extremity.
PROCEDURE PERFORMED: Primary repair left Achilles tendon.
ANESTHESIA: General.
COMPLICATIONS: None.
TOTAL TOURNIQUET TIME: 40 minutes at 325 mmHg.
POSITION: Prone.
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.
PROCEDURE: After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff. While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient. The patient was then transferred to the operative table and placed in the prone position. All bony prominences were well padded at this time.
Keywords: orthopedic, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity,