Manipulative Procedures Example 2

View the suggested abstraction.

Laryngoscopy Report

  • Hosp. No.: 000028
  • Name: Larry Easop
  • Service: ENT
  • Sex: Male
  • Age: 59
  • Race: White
  • Date of Operation: 08/07/91

Clinical Diagnosis Carcinoma of the larynx

Procedure Direct Laryngoscopy Anesthetic____________

Under general anesthesia and without intubation, the laryngoscope was inserted. The larynx was exposed. Immediately there was noted a fungating mass occupying the left supraglottic area up to the level of the aryepiglottic fold. The pyriform sinuses and the glottis itself were free of disease. A biopsy was taken. The cords were moving normally.

The mass, as was mentioned above, occupies the left supraglottic areas from the level of the false cord up to the aryepiglottic fold. It does not pass the midline. It was friable, but with no excessive bleeding.

The patient tolerated the procedure well and left the operating room in good condition.

Endoscopist Opie Endoes, MD
Assistant Andy Also, II, MD