Myringotomy and Tube Medical Transcription Operative Sample Report #1
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Chronic otitis media with hearing loss and chronic adenoiditis.
POSTOPERATIVE DIAGNOSES: Chronic otitis media with hearing loss and chronic adenoiditis.
PROCEDURES PERFORMED:
1. Adenoidectomy.
2. Bilateral myringotomy and tube.
ANESTHESIA: General.
BLOOD LOSS: Not significant.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table and given mask induction without problems. The IV was started. The patient was intubated. The operating microscope was brought into position. The right ear was examined.
An anterior-superior quadrant myringotomy incision was made and thick fluid was suctioned from the middle ear space. An Activent tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal.
A similar procedure was undertaken on the left side. The ear was cleaned of cerumen. An anterior-superior quadrant myringotomy incision was made and thick fluid was suctioned from the middle ear space. The same type of tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal.
The bed was turned 90 degrees. The McIvor mouth gag was placed in the oral cavity with a #2 blade. There was crusted purulent mucus in the nasal cavity. Culture of the nasopharynx was performed. The red rubber catheters were used to retract the palate.
Adenoids were moderately hypertrophic. Adenoid tissue was removed with the Coblation wand with a setting of 6 and 5 and suction Bovie cauterization was used to control bleeding. Intravenous Decadron was given at the start of the procedure.
The pharynx was irrigated and suctioned. The patient tolerated the procedure well. He was discharged to home on Augmentin, Orapred, Ciprodex and Tylenol or Motrin. Followup in the office will be within the next two weeks.
Myringotomy and Tube Medical Transcription Operative Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chronic otitis media with hearing loss, left ear.
POSTOPERATIVE DIAGNOSIS: Chronic otitis media with hearing loss, left ear.
PROCEDURE PERFORMED: Left myringotomy and tube.
ANESTHESIA: General.
BLOOD LOSS: Not significant.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table and given intravenous induction without problems. She was mask ventilated. The left ear was examined with an operating microscope. There were signs of chronic otitis media with tympanic membrane tympanosclerosis.
The previously inserted Touma T-tube was removed and granulation tissue around the ostial opening of the tube was removed.
The incision was enlarged with a #7120 Beaver blade and the same type of Touma T-tube was inserted in the tympanic membrane. Ciprodex drops were placed in the canal. The patient will follow up in the office within the next 7 to 10 days. Water precautions are to be maintained. The patient is to finish her present course of Levaquin.
