Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: ENT - Otolaryngology
Sample Name: Myringotomy/Tube Insertion - 1

Description: Bilateral myringotomies and insertion of Shepard grommet draining tubes.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Bilateral chronic serous otitis media.

POSTOPERATIVE DIAGNOSIS: Bilateral chronic serous otitis media.

OPERATION PERFORMED:
1. Bilateral myringotomies.
2. Insertion of Shepard grommet draining tubes.

ANESTHESIA: General, by mask.

ESTIMATED BLOOD LOSS: Less than 1 mL.

COMPLICATIONS: None.

FINDINGS: The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same. At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.

PROCEDURE: With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides. Bilateral inferior radial myringotomies were performed, first on the right and then on the left. Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side. Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally. At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.

Keywords: ent - otolaryngology, serous otitis media, floxin drops, shepard grommet, cerumen, cotton ball, middle ear, mucoid, myringotomies, tubes, shepard grommet draining tubes, serous otitis, shepard, grommet, insertion,
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