OPERATIVE REPORT
| DATE OF OPERATION: | 02/20/10 |
| PREOPERATIVE DIAGNOSIS: |
Bilateral ectropion with recurrent ptosis of the left eye. |
| POSTOPERATIVE DIAGNOSIS: |
Bilateral ectropion with recurrent ptosis of the left eye. |
| OPERATIVE PROCEDURE:
|
Bilateral ectropion repair with upper blepharoplasty of the left eye. |
| SURGEON: | Harry Richard, M.D. |
| ANESTHESIA: | Local with monitored anesthesia care. |
| SPECIMEN: | Skin fat excised. |
| ESTIMATED BLOOD LOSS: | Less than 5 cc. |
| COMPLICATIONS: | None. |
| DRAINS: | None. |
DESCRIPTION OF THE PROCEDURE: The patient was taken to the Operating Room and was placed in a recumbent position. A time out was conducted in which the patient’s identity, surgical eyes and procedure was verified by the surgeon, circulating nurse and scrub nurse. Using a Colorado needle, an initial incision in the lower eyelid margin on the premarked skin area was performed. The skin was undermined and bleeding vessels were carefully cauterized with a held cautery. The spectrum was opened and excess fat was removed and a lateral tarsorrhaphy was performed as well. The skin was closed with 6-0 plain suture. On the left upper eyelid, we also used a Colorado needle to make an initial elliptical incision on the premarked area of the skin. The skin was removed and it was closed with 6-0 Prolene suture. At the endo f the procedure, we gave 1 gm of Ancef and 8 mg of Decadron intravenously. The patient was sent to the Recovery Room without any complications where he received postoperative instructions and follow up appointments.
More Examples Of Medical Reports - Click here for more medical transcription reports examples.