Op Notes & DALS Flashcards
Microlaryngoscopy - Salient bits for op note:
- Mouthguard inserted to protect teeth
- Laryngoscopy performed
- Laryngoscope in suspension
- Microscope used to inspect cords
- Microdissection of vocal cord polyp
- 1:1000 adrenaline party used for haemostasis
- 24 hours voice rest
- Home tomorrow if well
Adenotonsillectomy - Salient bits for op note:
Grade 4 tonsils
Adenoids moderate
Adenoids curretted
Haemostasis with PNS pack
Cold steel dissection of ton sils with ties to lower poles
Diathermy at 15W for haemostasis
Teeth, temporomandibular joint, lips ok at end of procedure
Regular analgesia
No routine follow up
**Grommet op note **- Salient bits for op note:
Right - flat, dull tympanic membrane with large middle ear effusions
Left …….
Ear canal suction of wax a traumatically
Anterior inferior myringotomis performed
Effusions aspirated, Shah grommets inserted
Attics clear on right and left sides
Routine post operative observations
Eats and drink as able
Home today if well
Follow up with audiology in 2 months
Information sheet given to patient
**Nasal polypectomy **- DAL salient bits:
Presenting complaint…
Complications - none introperatively or post operatively
Medications:
- Given 4 weeks saline nasale douches
- To continue flixonase nasules 200mcg BD
- with instructions on administrations
- No toher changes to medications
Advice:
- All nasal packing removed before discharge
- Crusting and dry blood may cause nasal obstruction for 2 weeks
- Larger bleed may require re-admission
- 1 week off work
- Information leaflet given
Submandibular gland excision DAL - salient bits:
INVESTIGATIONS Sialogram - submandibular stone
OPERATION Right submandibular gland excision
MEDICATIONS
- Co-codamol 30/500 2 tablets four times a day as required
ADVICE
- Pain killers as able
- off work for one week
- If notice temperature, pain and swelling in the neck or difficulty to breathe please come to A+ E imme-
diately. Any concerns seek medical advice from GP or A&E.
FOLLOW UP
3 weeks in clinic
