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: Tonsillectomy & Adenoidectomy - 2

Description: Tonsillectomy & adenoidectomy. Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.

POSTOPERATIVE DIAGNOSIS: Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.

OPERATION PERFORMED: Tonsillectomy & adenoidectomy.

ANESTHESIA: General endotracheal.

FINDINGS: The tonsils were 3+ enlarged and cryptic.

DESCRIPTION OF OPERATION: Under general anesthesia with an endotracheal tube, the patient was placed in supine position. A mouth gag was inserted and suspended from Mayo stand. Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate. The adenoid area was inspected. The adenoids were small. The left tonsil was grasped with a tonsil tenaculum. The tonsil was removed with the Gold laser. The apposite tonsil was removed in a similar manner. Hemostasis was secured with electrocautery. Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline. The patient tolerated the procedure well and left the operating room in good condition.

Keywords: surgery, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy,
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