ENT - Otolaryngology
Sample Name: Tonsillectomy
Description: Tonsillectomy. Tonsillitis. McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Tonsillitis.
POSTOPERATIVE DIAGNOSIS: Tonsillitis.
PROCEDURE PERFORMED: Tonsillectomy.
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 a 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 on the upper lip to provide soft palate retraction. The nasopharynx was inspected with the laryngeal mirror.
Attention was re-directed to the right tonsil. The pack was removed and bleeding was controlled with the suction Bovie unit. Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs. The catheters were then removed. The nasal passages and oropharynx were suctioned free of debris. The procedure was terminated.
The patient tolerated the procedure well and left the operating room in good condition.
Keywords: ent - otolaryngology, tongue, palate, mcivor mouth gag, anterior tonsillar, metzenbaum scissors, oral cavity, tonsillar pillar, tonsillectomy, metzenbaum, tonsillitis, pillar, tonsillar, fossa,