Sample Type / Medical Specialty: ENT - Otolaryngology
Sample Name: Tonsillectomy & Adenoidectomy
Description: Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: Hypertrophy of tonsils and adenoids, and also foreign body of right ear.
POSTOPERATIVE DIAGNOSES: Hypertrophy of tonsils and adenoids, and also foreign body of right ear.
OPERATIONS: Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.
HISTORY: The patient is 5-1/2 years old. She is here this morning with her Mom. She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well. At the office we saw the tonsils were very big. There was a rock in the right ear and it was very deep in the canal, near the drum. We will remove the foreign body under the same anesthetic.
Keywords: ent - otolaryngology, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids,