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: Ear Examination

Description: Right ear examination under anesthesia. Right tympanic membrane perforation along with chronic otitis media.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Right tympanic membrane perforation.

POSTOPERATIVE DIAGNOSIS: Right tympanic membrane perforation along with chronic otitis media.

PROCEDURE: Right ear examination under anesthesia.

INDICATIONS: The patient is a 15-year-old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss. Exam in the office revealed a posterior superior right marginal tympanic perforation. Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother. The mother wished to proceed with surgery.

FINDINGS: The patient was brought to the room, placed in supine position, given general endotracheal anesthesia. The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with external meatus. An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected, a total of 4 mL local anesthetic was used. The ear was then prepped and draped in the usual sterile fashion. The microscope was then brought into view and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum. The granulation tissue was debrided as much as possible. Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible. The middle ear space was filled with Floxin drops. The patient woke up anesthesia, extubated, and brought to recovery room in stable condition. There were no intraoperative complications. Needle and sponge was correct. Estimated blood loss minimal.

Keywords: ent - otolaryngology, chronic otitis media, middle ear space, tympanic membrane perforation, otitis media, hearing loss, middle ear, ear space, ear examination, membrane perforation, tympanic membrane, anesthesia, membrane, tympanic, ear, perforation,
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