ENT Case Study

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 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 of 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 0.5% hydrocortisone cream in the outer ear and a couple drops of alcohol at night before he goes to bed.  Try to keep the canal dry.  Nasal irrigation 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 serous 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 followup.

IMPRESSION

External otitis.

DISPOSITION

Spectazole and followup.

FOOTNOTE

Line 8 (Page 1).  ITE was translated for clarity.

Line 11 (Page 1).  Ocean is a trade name for a nasal spray.

Line 13 (Page 1).  Exam was expanded to Examination in the report.

Line 28 (Page 1).  The dictated one-half percent is represented correctly as 0.5% for metric measurement consistency.