Preoperative Diagnosis:
- Cataract in the left eye
Postoperative Diagnosis:
- Cataract in the left eye
Procedure:
- Phacoemulsification with intraocular lens implantation
Surgeon:
- Dr. Emily Carter
Assistant:
- Dr. John Smith
Anesthesia:
- Local anesthesia with sedation
Indications:
- Significant visual impairment affecting daily activities
Findings:
- Dense nuclear cataract in the left eye
Procedure Details:
- A clear corneal incision was made, and phacoemulsification was performed to remove the cataract. An intraocular lens was implanted in the capsular bag. The incision was self-sealing, and no sutures were required.
Complications:
- None
Estimated Blood Loss:
- Minimal
Specimens:
- None
Disposition:
- Patient was stable and transferred to the recovery room in good condition.
Follow-Up:
- Patient to follow up in one week for postoperative evaluation.
Preoperative Diagnosis:
- [preoperative diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Postoperative Diagnosis:
- [postoperative diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Procedure:
- [name of the procedure] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Surgeon:
- [name of the surgeon] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assistant:
- [name of the assistant] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Anesthesia:
- [type of anesthesia used] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Indications:
- [indications for surgery] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Findings:
- [intraoperative findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Procedure Details:
- [detailed description of the procedure] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Complications:
- [any complications encountered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Estimated Blood Loss:
- [estimated blood loss] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Specimens:
- [specimens removed and sent for pathology] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Disposition:
- [patient's condition and disposition post-surgery] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Follow-Up:
- [follow-up instructions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
