MRN: XXX
Date of Surgery: XXX
PREOPERATIVE DIAGNOSIS:
Ruptured globe OX.
POSTOPERATIVE DIAGNOSIS:
Ruptured globe OX.
PROCEDURE:
Repair of ruptured globe OX.
SURGEON: XXX
ATTENDING: XXX
ANESTHESIA: General
SPECIMENS:None.
COMPLICATIONS: None.
INDICATIONS: This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.
PROCEDURE: The risks and benefits of eye surgery were
discussed at length with the patient, including bleeding, infection,
re-operation, loss of vision, and loss of the eye. Informed consent
was
obtained.
The patient received IV antibiotics including Ancef and
Levaeuin prior to surgery. The patient
was brought to the operating room and placud in the supine
position, where (s)he wad prepped and draped in the routine fashion.
A wire lid speculum was
placed to provide exposure.
Upon examination and dissection of the conjunctiva superiorly, a
scleral rupture was found. The rupture extended approximately 15
mm in length superior to the cornea, approximately 2 mm from the
limbus in a horizontal fashion. There was also a rupture at the
limbus, near the middle of this laceration, causing the anterior
chamber to be flat. There was a large blood clot filling the
anterior chamber. An attempt was made to wash out the anterior
chamber with BSS on a cannula. The BSS was injected through the
limbal rupture, which communicated with the anterior chamber.
The blood clot did not move. It was extremely adherent to the
iris.
At that time, the rupture that involved the limbus from
approximately 10:30 until 12 o'clock was closed using 1 suture of
10-0 nylon. The scleral laceration was then closed using 10
interrupted sutures with 9-0 Vicryl. At that time, the anterior
chamber was formed and appeared to be fairly deep. The wounds
were checked and found to be watertight. The knots were rotated
posteriorly and the conjunctiva was draped up over the sutures
and sewn into position at the limbus using four 7-0 Vicryl
sutures, 2 nasally and 2 temporally. All suture knots were
buried.
Gentamicin 0.5 cc was injected subconjunctivally. Then, the
speculum was removed. The drapes were removed. Several drops of
Ocuflox and Maxitrol ointment were placed in the XXX eye. An
eye patch and shield were placed over the eye. The patient was
awakened from general anesthesia without difficulty and taken to
the recovery room in good condition.
Don't forget to record the dictation number once you finish the dictation and note it somewhere in the chart, so you can track down the dictation if it mysteriously disappears.