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: Adenotonsillectomy - 1

Description: Adenotonsillectomy. Recurrent tonsillitis. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Recurrent tonsillitis.

POSTOPERATIVE DIAGNOSIS: Recurrent tonsillitis.

PROCEDURE: Adenotonsillectomy.

COMPLICATIONS: None.

PROCEDURE DETAILS: The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed. A similar procedure was performed on the contralateral tonsil. Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted. The patient was then allowed to awaken and was brought to the recovery room in stable condition.

Keywords: surgery, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy,
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