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Tonsillectomy Medical Transcription Sample Reports

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic tonsillitis and tonsillar hypertrophy.

POSTOPERATIVE DIAGNOSIS:  Chronic tonsillitis and tonsillar hypertrophy.

PROCEDURE PERFORMED:  Tonsillectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

FINDINGS:  Absence of adenoid tissue and 3+, very smooth tonsils.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old with a history of recurrent strep infections of the tonsils with newly developed sleep-disordered breathing from tonsillar hypertrophy, who presents for removal of tissue.

DESCRIPTION OF PROCEDURE:  After informed consent was reviewed with the patient, the patient was brought to the operating room and placed on the table in the supine position. Once a suitable plane of anesthesia was obtained, the Anesthesia personnel performed endotracheal intubation. Next, the patient was draped in standard fashion. A Crowe-Davis mouth gag was inserted to exposed the oral cavity. Tonsils were palpated and were normal. The patient was placed in suspension. The Crowe-Davis was then suspended from the Mayo stand. The right tonsil was grasped and retracted medially and Bovie cautery was used to dissect the tonsil from the tonsillar fossa. This procedure was repeated on the left side. Hemostasis was achieved with suction Bovie. Next, a red rubber catheter was passed through the nasal cavity and into the mouth to provide retraction on the palate. The adenoid bed was inspected with a laryngeal mirror and was found to be normal. At this point, the tonsils were reinspected and irrigated. There were no signs of active bleeding. An nasogastric tube was passed into the stomach. The stomach contents were suctioned. At this point, the red rubber catheter and Crowe-Davis mouth gag were removed and care was turned over to Anesthesia for extubation. The patient was extubated in the OR and was stable upon transport to the PACU.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic tonsillitis.

POSTOPERATIVE DIAGNOSIS:  Chronic tonsillitis.

PROCEDURE PERFORMED:  Tonsillectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

SPECIMENS:  Bilateral tonsils.

BRIEF HISTORY:  The patient is a (XX)-year-old gentleman with a history of chronic tonsillitis, tonsilloliths and halitosis. The patient elected to undergo a tonsillectomy. The risks and benefits of the procedure were explained to the patient, and he agreed to proceed.

FINDINGS:  The patient had large cryptic tonsils with retained food products bilaterally.

DESCRIPTION OF PROCEDURE:  The patient came to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was turned, and the patient was draped in routine fashion. A Crowe-Davis mouth gag was used to visualize the oral cavity and the oropharynx. The right tonsil was grasped with a tonsil clamp and medialized. Bovie cautery was then used to dissect the tonsil free from the tonsillar fossa. There was no bleeding during the removal. The tonsil was then sent for routine pathological diagnosis. Attention was then turned towards the left tonsil. This was grabbed with a tonsil clamp and medialized. Bovie cautery was then used to excise the tonsil from the tonsillar fossa. Again, there was no bleeding during this part of the procedure. The tonsil was removed and sent for permanent pathology. The oropharynx was then thoroughly irrigated with normal saline. Suction Bovie cautery on a low setting was used to cauterize superficial vessels, which were identified on inspection bilaterally. After hemostasis with the suction Bovie cautery, the oropharynx was again thoroughly irrigated with normal saline. There was no evidence of bleeding at the end of the case. At that point, the Crowe-Davis mouth gag was removed. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition without any immediate apparent complications.

More Tonsillectomy Samples   ENT Operative Samples #1   ENT Operative Samples #2