PROCEDURAL NOTE
PATIENT: Ortiz, Pamela
AGE: 12
DATE: 04/16/2015
PREOPERATIVE DIAGNOSIS: Obstructive Sleep Apnea
POSTOPERATIVE DIAGNOSIS: Obstructive Sleep Apnea
PROCEDURE: Tonsillectomy and Adenoidectomy
The patient was anesthetized and placed on the operating table in a supine position. Her mouth was set open to allow access to the tonsils at the beginning of the pharynx. Both tonsils and adenoids appeared to be grossly enlarged. Using electrocautery, the patient’s tonsils were dissected from the subcapsular plane and removed from the pharynx. Minimal bleeding was noted on the right side of the tonsillar excision, which was cauterized to stop the bleeding. Adenoids were dissected in the same manner and no bleeding was noted. Thrombin was applied to both sides of the tonsillar excision to induce clotting and stop any additional bleeding that might occur postoperatively. The patient tolerated the procedure well and was given a pain medication prescription for possible throat pain. The physician recommended that the patient only consume cold foods and liquids for postoperative pain management. The patient was scheduled for a follow-up exam in one week.
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