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Sample Transcribed Reports:


ENT . . . Page 1


These reports are samples of basic clinical evaluations of patients seen by an otolaryngologist. The sample reports have been checked for accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference of the dictating physician.


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Edited Sample Report

Thank you for referring this patient who was seen regarding her nasal allergies. She also developed a pneumonia and was put on prednisone which has in fact improved her nasal function by reducing the polypoid change in the nose. She is breathing quite well through the nose, has a good sense of smell, and ears are feeling well.

Examination: Revealed a moderate degree of hyperemic change and congestion to the nose, consistent with a viral rhinitis. There are some very high polyps bilaterally which are certainly not obstructive to her airway. The throat and larynx were clear. Otoscopy shows the left ear to be normal. The previously inserted tube in her right ear has now extruded, the drum has healed, and there is no fluid in this ear either.

Diagnosis:  Ongoing allergic rhinitis and polyposis problem with superimposed viral rhinitis.

Plan:  Once her cold settles, I have asked her to start using the Nasacort spray again on a regular basis and to see me again in June, or sooner if she notices a loss of sense of smell again.

Edited Sample Report

Thank you for referring this patient who was seen regarding evaluation of hearing loss. Hearing allegedly is generally reduced in both ears, but he has always, throughout his entire life, had worse hearing in his left ear, presumably subsequent to childhood otorrhea which he does recall.

Examination: Revealed an intact right tympanic membrane. He has a relatively small posterosuperior perforation of the left drum which unfortunately overlies the stapes incus and to a slight degree, the round window. He also has a bit of otomycosis infection involving the proximal ear canal, although no evident involvement of the middle ear.

Lab:  Audiometry shows a mild to moderately-severe bilateral nerve deafness of symmetric degree with a substantial additional conductive deafness in his left ear due to the perforation. Speech levels averaged approximately 35-40 dB in the right ear and about 80 dB in the left ear.

Diagnoses: 1) Mild to moderately-severe bilateral sensorineural hearing loss.
               2) Perforated left tympanic membrane with moderate conductive deafness.
               3) Otomycosis, left ear canal.

Plan:  The ear was cleaned and I have applied a Canesten ointment to the entire canal and will follow-up in a month. His option is either to use a hearing aid in the left and/or both ears to get better hearing, or to undergo tympanoplasty surgery to his left ear to close the perforation. He can then see how he feels about his hearing loss, of which the sensorineural component will remain, to see whether subsequent hearing aids are still needed. He will give me his decision on these options when he returns for a recheck of his otomycosis.


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Edited Sample Report

Thank you for referring this patient who was seen about possible hearing loss in the right ear, or just a feeling of blockage. He seems to feel that he does not hear as well, especially with regard to clarity of the spoken word and especially when hearing in background ambient sound. No history of noise exposure; no history of imbalance, and tinnitus is only a minimal buzzing of intermittent nature.

Examination: Revealed a normal ear, nose, throat, head, and neck exam.

Lab:  Audiometric testing does reveal a normal to moderate sensorineural hearing loss in the right ear and a normal to marginal to moderate sensorineural loss in the left ear.

Diagnosis:  Marginal to mild sensorineural hearing loss, minimally worse left ear.

Plan:  Because of the slight asymmetry in the speech area, I am going to send him for an ABR study, although I suspect it will be normal. Hearing loss is not sufficient to warrant amplification at this time but assuming his ABR is normal, I have only recommended reassessment in two years.

 

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