How to Answer Medical Record Male Questions (Complete Guide)

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Original Question

MEDICAL RECORD SEX: Male AGE:38 DATE OF SERVICE: 01/01/20XX DIAGNOSIS: Chronic Tonsillitis ANESTHESIA: GENERAL DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and placed supine on the operating room table. General anesthesia was administered. An orotracheal tube was placed by the anesthesiologist. The operating room table was then turned to the left 90 degrees and the patient’s head and neck region was prepped and draped in the usual fashion for bilateral tonsillectomy. A shoulder roll was placed. A Crowe-Davis mouth retractor was inserted and a head drape was positioned. The patient’s eyes were also protected. Upon opening the Crowe-Davis mouth retractor, there was no evidence of bifid uvula or submucous clefting. Red rubber catheters were then passed through the nose into the oral cavity to retract soft palate anteriorly. Straight Allis clamps were used to grasp the tonsils at the superior pole and retract the tonsils inferomedially. Using the Coblation device on coagulation settings. The tonsils were dissected out of the tonsillar fossae from superior to inferior along the tonsil capsule. Once the tonsils were removed from the fossae, adequate hemostasis was obtained in the tonsillar fossae using the Coblation device on coagulation settings. Copious amounts of saline were irrigated into the oral cavity and orogastric suction was then passed to evacuate stomach of its secretions. Naropin 0.5% was also infiltrated into the anterior and posterior tonsillar pillars approximately 3 mL was used in total. Upon releasing the Crowe-Davis mouth retractor for one minute and opening there was no evidence of bleeding. The patient was then turned back around to the anesthesiologist for extubation. Upon awakening from extubation, there seemed to be bleeding arising from the nose. The Crowe-Davis mouth retractor was then reinserted and there was found to be bleeding within the nostril on the right as well as the left tonsillar fossa. These bleeding sites were controlled using Coblation device rather on coagulation settings. The patient was then extubated without any complications and escorted uneventfully to ambulatory recovery room. Electronically signed by . 01/01/20XX

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