Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Myringotomy/Tube Insertion

Description: Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.

POSTOPERATIVE DIAGNOSES: Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.

OPERATION: Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.

ANESTHESIA: General via facemask.

ESTIMATED BLOOD LOSS: None.

COMPLICATIONS: None.

INDICATIONS: The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.

PROCEDURE: The patient was brought to the operating room, was placed in supine position. General anesthesia was begun via face mask technique. Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal. A small amount of wax was removed with a loop. A 4-mm operating speculum was then introduced. An anteroinferior quadrant radial myringotomy was then performed. A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft. Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus. Head was then turned to the opposite side, where similar procedure was performed. Once again, the middle ear cleft had a mucoid effusion. A tube was inserted to an anteroinferior quadrant radial myringotomy.

Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.

Keywords: surgery, bilateral myringotomies, insertion of pe tubes, chronic otitis media, conductive hearing loss, recurrent acute otitis media, reuter bobbin, radial myringotomy, ear cleft, pe tubes, middle ear, otitis media, effusion, otitis, media, ear, anesthesia,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples