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Edited Sample Report

This patient is a ***-year-old boy who gets tonsillitis maybe two or three times a year and his mother is concerned because his tonsils remain enlarged in-between attacks and also because he sometimes has a snoring problem.

On Exam:  The nasal airway seems to be adequate. Both tonsils are average size and not considered to be too enlarged and do not seem to be causing any obstruction of the airway. Eardrums and ear canals are normal.

The mother was reassured that T&A is not required at this stage and that the adenoid tissue will regress and the snoring problem will eventually diminish.

Edited Sample Report

This is a follow-up report on this patient who was recently sent for brainstem audiometry and a CAT scan because the x-ray of the internal auditory canals revealed slight enlargement on the right side. The ABR test was quite normal and the CAT scan did not show any sign of acoustic nerve neuroma.

Clinically, she still has some tinnitus in the right ear but the audiometric testing indicated her hearing is quite normal, with a speech reception threshold of 10 dB on both sides and there is no asymmetry of her hearing threshold.


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Edited Sample Report

This patient is a ***-year-old gentleman who, two weeks ago, developed a spontaneous swelling of the left parotid gland which stayed for two days. It is not very painful to touch and this has never happened before.

On Exam:  The swelling of the parotid gland has resolved. There is no facial nerve dysfunction. Palpation of the left parotid duct is normal. Eardrums and ear canals are normal.

The patient recently had obstructive sialadenitis of the left parotid gland which is probably due to obstruction of the main duct by a mucous plug, perhaps secondary to poor hydration during the hot summer days.

The condition has now resolved. I do not think we need to pursue further investigation. If he develops any further problem, he will come back to see us for follow-up.

Edited Sample Report

This patient is a ***-year-old patient who complains of always having excessive mucous in her throat. Sometimes, she even has a low-grade sore throat radiating to the ears. Her barium swallow seemed to indicate some degree of reflux problem. She has been treated with different types of antireflux medication without much improvement. She has Type II diabetes. The patient is leaving for a trip in two days' time and will not be back for three months.

On Exam:  Examination with the flexible fibreoptic scope revealed the vocal cords are moving well. There is no mucosal disease on the vocal cord surface. Hypopharynx is normal. However, there is some hypertrophic mucosa at the posterior commissure, suggesting she may indeed have some reflux problem causing this hypertrophy of the posterior laryngeal mucosa.

I prescribed some Gaviscon lozenges for her and she will come back after her trip for a follow-up examination.

Diagnosis:  Gastroesophageal reflux, causing hypertrophic change of the posterior laryngeal mucosa.

Edited Sample Report

This patient apparently was eating some fish three weeks ago and a small piece of bone stuck in her throat. Even now, she still feels a foreign body sensation at the back of her throat on the left side. A soft-tissue x-ray of her neck did not show any foreign body but did show some calcification of the inferior hyoid bone, probably related to the calcified laryngeal cartilage.

On Exam:  Examination today with a flexible fibreoptic scope revealed a small blood blister at the base of the tongue, near the vallecular fossa, towards the left of the midline. This is probably the site of the salmon bone scratch.

I reassured the patient that there was no foreign body present. A small bruise at the base of the tongue is related to the previous fish bone trauma but the foreign body has been dislodged and probably swallowed. The area at the base of the tongue will heal in the next little while.

Edited Sample Report

This patient is complaining of a stuffy nose, usually at nighttime. She had an operation on her nose about 11 years ago, which consisted of a turbinate resection and septoplasty.

On Exam:  The septum is a bit deviated to the right. The turbinates are normal size. There is no polyp in the nose. The nasal airway seems adequate.

I do not think a revision septoplasty is required. I prescribed some Rhinocort nasal spray for her to use on a p.r.n. basis.

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