ENT FILES

ENT_5

EMERGENCY ROOM REPORT

He was brought to the emergency room with a right epistaxis with clots in the nose.  Patient is on Coumadin.

EXAMINATION:  Clots were removed from the right nostril, and an active venous bleeder on the right anterior septum was identified.  This was cauterized with silver nitrate and an anterior pack placed.  The left side appeared to have no active bleeding.  He was observed for a few minutes, and no further bleeding of an active nature was identified.  Some tape as counter pressure was applied to the nose, and the throat checked also.  There is just an old clot posterior that is sticking down just enough so that you can see it but cannot reach it with an instrument.  This was left in place.

I recommend that we leave the pack in until Wednesday morning if patient tolerates it.  He is apparently already on antibiotics, pain medicines, and oxygen, so no additional orders are indicated at this time.

ENT_6

CHART NOTE

Examination of right postauricular mastoid wound site demonstrates less erythema with mild induration, and packing demonstrates thick, cloudy secretions with no malodor.  There appear to be no frank pus pockets evident, and debridement was performed with application of Betadine ointment.  Betadine-impregnated iodoform gauze was additionally placed with approximately 1-1/2 inches and patient’s wife instructed in wound care.

ASSESSMENT:  Right postauricular mastoid wound infection with fat or hematoma liquefaction.

ENT_7

CONSULTATION

This 17-year-old woman was seen in consultation with her mother regarding problems referable to her nose.  The patient has had progressive problems of congestion and sniffing with difficulty moving air through her nose and sensation of pressure.  She is a “mouth breather,” and has a history of allergy to pollens and dust.  Patient feels these problems are becoming more severe.  Her complaints are fairly consistent.

EXAMINATION:  She presents with edema of her nasal mucosa, increase in the size of the turbinates, deviation of the nasal septum, and a rather narrowed nasal airway.

DIAGNOSES

1.Probable allergic rhinitis with hypertrophy of the turbinates.

2.Deviated nasal septum.

3.Narrow inadequate nasal airway.

COMMENTS

1.  I have discussed with this patient and with her mother the surgical approach to improving her nasal airway with septoplasty, and possible submucous resection of deviated portions of the septum, and possible reduction of the inferior turbinates.  At the same time I would be performing a rhinoplasty procedure to smooth out the dorsal nose as well.

2.  Because of the history of allergies to pollens, dust, and environmental pollutants, it is quite possible patient will continue to have some sniffing, and consequently the degree of improvement of her nasal airway with surgery cannot be precisely determined.

ENT_10

LETTER

Date

Name

Address

City, State, Zip

Re:

Dear Al

This 21-year-old lady stated that she has been having some problems with a “swollen gland on the right side.”  She had seen you about a week and a half ago, and you had ruled out the presence of a stone within the salivary gland.  She states the swelling “tends to go up and down.”

Her general health is described as good, but she does have asthma.  She is presently taking Motrin, Marax, and an inhaler.

Physical examination reveals ear canals are clear.  Tympanic membranes normal.  Nasal airway adequate, no discharge.  Throat reveals normal mucous membrane.  No postnasal drainage.  Her right submandibular gland is slightly enlarged but soft and nontender.

Under the operating microscope, I was able to dilate Wharton duct on the right, and after dilatation the gland resumed its normal size.  There was no evidence of purulent discharge or calculi.  Hopefully, this will do the trick.

I explained to her we can only treat this either symptomatically or excise the gland, and I suggested that symptomatic treatment for a while is indicated.

Thank you to demonstrate proper letter format.

ENT_11

CHART NOTE

PHYSICAL EXAMINATION:

Ear canals are clear.  Tympanic membranes are normal.

Nasal airway is adequate.  Septum slightly deviated to the right.  No discharge.  Throat reveals normal mucous membrane.  No evidence of inflammation.  No PND (postnasal drainage).  She does have a couple little lymphoid plaques, both in the pharynx and in the area where tonsils were removed.  These are not neoplasms and not presently inflamed, just a tiny bit juicy.  Neck reveals no adenopathy.  Thyroid and trachea are normal.

IMPRESSION:  Very mild lymphoid hyperplasia of the tonsillar fossae postoperative and the nasopharynx.

DISPOSITION:  Reassured.  Explained what is going on, and she is to return p.r.n.  Encouraged her not to take antibiotics for just every sore throat.

ENT_12

HISTORY AND PHYSICAL EXAMINATION

An 11-7/12-year-old female who states that she has heard a noise in her right ear off and on for the past few weeks.  She has had no fever, no rhinorrhea, no cough, no vomiting, no diarrhea, no dizziness, no headache.  She has suffered no loss of consciousness.  She takes no medications at the present time.

PAST MEDICAL HISTORY:  No hospitalizations.  No operations.  No allergies.  Immunizations are current.

PHYSICAL EXAMINATION

GENERAL:  Alert, well-nourished, well-developed female in no acute distress.

SKIN:  Clear.

HEENT:  Eyes:  Sclerae white.  Conjunctivae clear.  Fundi within normal limits.  Ears, nose, throat entirely within normal limits.

NECK:  Supple.  No adenopathy.

LUNGS:  Clear.

HEART:  Regular rate and rhythm without murmurs.

ABDOMEN:  Soft, nontender.  No masses no hepatosplenomegaly.

EXTREMITIES:  No clubbing, cyanosis, or edema.

GENITALIA:  Normal Tanner stage II female external genitalia.

NEUROLOGIC:  Tone within normal limits.

Deep tendon reflexes 2+.  Finger-to-nose intact without tremor.  Audiometry is within normal limits.

IMPRESSION:  Questionable tinnitus-etiology unclear.

PLAN

1.  Symptomatic care.

2.  Return to clinic if tinnitus does not resolve.

3.  Hemoglobin.

4.  Urinalysis.

5.  TB tine.