ENT TEST FILES

ENT_T1

CHART NOTE

The patient comes in stating he has some irritation in his right ear.  He does wear an ITE (in-the-ear) aid on that side.  He also has what he terms a smell hallucination in that there is kind of a musty smell in his nose when he inhales and exhales.  He has been using some Ocean and spray from time to time.

PHYSICAL EXAMINATION

Examination of the ears reveal that in the right ear, external canal is slightly irritated at the outer third, but the inner two-thirds is okay.  Tympanic membrane is intact and not inflamed.  Left ear is clear.  There is no cerumen in either side.  Examination to the nose reveals the airway is quite adequate.  Septum slightly deviated to the right.  No evidence of polyps or abnormal discharge.  Throat reveals normal mucous membrane.  No evidence of inflammation.  Neck reveals no adenopathy.

IMPRESSION:  Mild right external otitis.

DISPOSITION:  Recommended the 0.5% hydrocortisone cream in the outer ear and a couple drops of alcohol at night before he goes bed.  Try to keep the canal dry.  Nasal irritation using a normal saline solution, and he was asked to return if symptoms progress and we will go ahead and get a sinus view.

CHART NOTE

Examination of his right ear reveals some inflammation of the tympanic membrane, a little moisture in the canal.  I am sure he has a serious otitis back there, but rather than put a tube in at the present time, give him some Ceclor 250 mg #30 and ask him to return in 2 weeks for tube insertion.

CHART NOTE

PHYSICAL EXAMINATION:  Right ear canal is small and swollen, difficult to work with, and required the operating microscope.  By use of both suction and hydrogen peroxide irrigation, a rather large bolus of fungus was removed from the tympanic membrane.  Tympanic membrane appeared intact.

Spectazole was then applied after drying the canal, and she was asked to return for follow-up.

IMPRESSION:  External otitis.

DISPOSITION:  Spectazole and follow-up.

ENT_T2

LETTER

Date

Name

Address

City, State, Zip

Re:

Gentlemen

At the request of my patient, I am forwarding this brief medical report.

HISTORY:  The patient, a 24-year-old woman, was seen in consultation regarding problems referable to her nasal breathing.  The patient complains of progressive congestion, a pressure sensation within the nose, sniffing, and stuffiness.  In addition, she has had episodes of sneezing, itching, and watery eyes.  She has more problems breathing through the right side of the nose than the left.

EXAMINATION:  Examination reveals the nasal septum to have somewhat of an S-shaped configuration with the midsection curved to the right of the midline and the caudal edge of the quadrilateral cartilage to the left of the midline.  There is marked obstruction of the right nasal passage.  She has some asymmetry to the dorsal nose as well.

DIAGNOSES:

1.  Inadequate nasal airway.

2.  Deviated nasal septum.

3.  Possible rhinitis.

COMMENTS:

1.  I have discussed with the patient the treatment of this condition with a nasal septoplasty with partial submucous resection.

2.  In addition, simultaneously a modified rhinoplasty would be performed.

3.  The patient would appreciate a letter from Blue Cross stating that these treatments would be covered on her health insurance program.

4.  The surgery would be performed in an office setting and would not require any hospitalization.

Sincerely

Name

ENT_T3

ENT

LETTER

Date

Re:

To Whom It May Concern

Michelle was first seen by me in February.  At that time she was complaining of vague symptoms.  She was under stress, but this was related to her work.  She also had a history of a kidney stone.

On examination at that time, she had red scaly patches under her ears, which subsequently turned out to be an allergy to her hair spray.  She had a left cervical posterior triangle node which was mobile and nontender, a scar over her right scapula where she had a hemangioma at age 6 weeks, and bilateral mammary inplants.

All the blood tests that were obtained were negative except for a low ferritin, related to her menstruating and her 2 pregnancies.  She was put on iron supplements.  She had a chest x-ray that was entirely normal.

She was seen again about a month later.  Her cervical node and axillary node had disappeared by then.  Because her nodes disappeared, she did not see a hidden head and neck surgeon, and on examination today she certainly does not have these nodes.  A copy of her lab data is enclosed, and this was all essentially normal aside from the low ferritin.

In 1986, her blood pressure was 92/56 and she weighed a 109-1/4 pounds.  Today her blood pressure is 106/60 and she weighs 111 pounds.  There has been no change in her blood pressure or her weight.

On examination today she still has the scar over her right shoulder blade.  I cannot today feel any axillary or cervical node enlargement whatever.  She still has the bilateral breast implants and a low C-section scar.  She tells me that she had a recent pelvic, Pap smear, and rectal examination by her gynecologist, and this was not done.  At the moment she is asymptomatic.  Indeed, she is only seeing me now because she is apparently having some trouble in getting medical insurance-this despite the fact that she has not seen a physician for any problems since last seeing me for a routine check-up.

I have ordered no routine or other blood studies at the time of this dictation.  She has had a recent Pap smear, is asymptomatic, is taking iron, and blood tests were essentially negative.  She has continued to feel good, not required medical care, and informs me that she has been in good health and seen no other physician during this time.

Sincerely yours

Name.