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: Adenoidectomy - 1

Description: Adenoidectomy. Adenoid hypertrophy. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Adenoid hypertrophy.

POSTOPERATIVE DIAGNOSIS: Adenoid hypertrophy.

PROCEDURE PERFORMED: Adenoidectomy.

ANESTHESIA: General endotracheal.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia. The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction. The nasopharynx was inspected with the laryngeal mirror. Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.

Attention was then redirected to the oropharynx. The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit. The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris. The McIvor was then removed, and the procedure was terminated.

The patient tolerated the procedure well and left the operating room in good condition.

Keywords: surgery, palate, nasal passage, mcivor mouth gag, oral cavity, nasal, nasopharynx, oropharynx, hypertrophy, oral, cavity, mcivor, tongue, adenoidectomy,
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