Download 耳鼻喉科標準病歷範本

耳鼻喉科標準病歷範本
一.【SMP】
Chief complaint:
Nasal obstruction, mouth breathing and postnasal drip for many years.
Present illness:
This 42 y/o male patient has suffered from unilateral right nasal obstruction, mouth
breathing, and postnasal drip for many years. Watery rhinorrhea, sneezing and headache
were also noted. He visited LMD and our ENT OPD for help, where deviation of nasal
septum with hypertrophic inferior turbinate was noted on physical examination. He had
received medical treatment but nasal obstruction persisted. He denied purulent rhinorrhea,
epistaxis or with foul smell. Under the tentative diagnosis of NSD + CHR that had been
treated in vain, he was admitted for surgical management.
二.【FESS】
Chief complaint:
Purulent rhinorrhea, headache and nasal obstruction for many years.
Present illness:
This 39 y/o male patient has suffered from purulent rhinorrhea for a long time. Nasal
obstruction, post-nasal drip and headache off and on were also noted. He visited LMD for
help, where chronic sinusitis with nasal polyps was told. He was then transferred to our
ENT OPD. At our OPD, sinus Xray was taken and showed cloudiness in the bilateral
maxillary sinuses. Sinoscopy was performed and mucopus and nasal polyps in the nasal
meatus were found; nasal septum deviation and hypertrophic rhinitis were also noted.
Medication was prescribed but the symptom of rhinorrhea persisted. He denied orbital pain,
diplopia or facial pain. Under the tentative diagnosis of chronic sinusitis with nasal
polyps, NSD + CHR that had been treated in vain, he was admitted for surgical
management.
三.【COM】
Chief complaint:
right progressive hearing loss, purulent otorrhea, ear pain, vertigo, headache, facial
paresis for many months
Present illness:
This ______ y/o man has suffered from right progressive hearing loss, purulent otorrhea,
aural discomfort, vertigo, headache, facial paresis for many months. He had visited local
ENT clinic once where he was treated with topical antibiotic drop but otorrhea persisted.
Purulent discharge tended to be thick, scanty, and fetid. He was transferred to our ENT
department for survey.
Physical exam showed right perforative tympanic membrane,
injected external auditory canal, attic retractions with pocket and cholesteatoma tissue.
His auditory testing with pure tone audiometry revealed 0-10-10-5-20 dB/0.5-8K/R't air;
*-*-*-*- dB/0.5-4K/R't bone. Patient denied fever, retroorbital pain, facial paralysis,
headache or focal neurologic signs on the side of the infected ear. We talked to the patient
about possible intratemporal and intracranial complications. Under the impression of right
chronic otitis media that had been treated in vain, he was admitted for further evaluation
and surgical treatment.
四.【LMS】
Chief complaint:
Husky voice for 6 months
Present illness:
This 42 y/o male patient has suffered from husky voice for 6 months. Voice abuse was
noted for months. Symptoms have progressed with vocal fatigue recently. He had visited
LMD for help where he was treated in vain. So, he visited our OPD for further exam.
Physical examination with mirror showed vocal slit. Stroboscopy was performed and
showed bilateral vocal nodule without vocal palsy. He denied trauma, neck surgery,
stroke history, dysphagia and respiratory symptoms. Under the impression of bilateral
vocal nodule, he was admitted for laryngomicrosurgery.
五.【Sudden hearing loss】
Chief complaint:
Right hearing impairment for 3 days
Present illness:
This 42 y/o male patient has suffered from right hearing impairment for 3 days. Tinnitus
with mild dizziness was also noted. He had visited LMD for help but symptoms persisted.
So, he was transferred to our OPD. Physical examination showed bilateral intact eardrum.
PTA was performed at OPD and showed right hearing loss more than 30 dB without AB
gap. He denied vertigo, trauma, cough, noise exposure, otorrhea and URI symptoms.
Under the impression of right sudden hearing loss, he was admitted for high dose steroid
treatment.
六. 【Benign neck mass】
Chief complaint:
Palpable neck mass for many months
Present illness:
This _____y/o man has suffered from palpable swelling neck mass for months. He had
received medical treatment in ENT clinics but it was not improved. He was transferred to
our ENT department where physical exam was performed and revealed a mass in the
left/right neck, 10 mm in size. Solid, on tender cyst with density was also noted. Patient
denied fever or chills, recent infection history, significant body weight loss and previous
operative history of head and neck. Endoscopy exam showed smooth nasopharynx, no
bulging lesion in the larynx and pharynx region and freely movable vocal cord region.
Neck Echo/CT:______. Cytology: negative of malignancy. Differential diagnosis of benign
neck lymadenopathy, thyroglossal duct cyst, thyroid goiter, dermoid cyst was made. We
reviewed his history of cigarette smoking, betal nut chewing, and alcohol drinking, which
all are risk factors for suspected cancer. After discussion with patient, he was admitted for
further evaluation, surgical treatment, and pathologic study.
七.【NPC】
Chief Complaint:
Right/Left neck mass noted for several months
Right/Left hearing impairment with aural fullness for several months
Severe headache noted for several years
Bloody tinged sputum noted for several months
Present illness:
This 49 year-old male patient has habits of smoking and drinking for more than ten years.
He had history of 1) 過去病史 2) 過去病史. This time, he was admitted due to 症狀
＋時間. According to himself, he has suffered from progressive enlargement of neck mass
for several months. Besides, blood tinged sputum and nasal discharges were noted.
Occasionally, nasal congestion on one side of his nose was also complained. Left/ right
hearing impairment, aural fullness, persistent headache, and double vision were noted. He
complained of facial/neck numbness, pain sensation, lower back pain. A persistent dry
cough was noted for several months. He had consumed some salt cured food or preserved
meats. No known family member has the same history of nasopharyngeal carcinoma.
He went to our ENT OPD for help. Physical examination showed a palpable, firm/elastic,
fixed/movable mass in the right/left neck with size about 2*3 cm. No significant
neurological signs were noted on neurological examination. Nasopharyngoscopy revealed a
bulging nasopharyngeal mass coated with blood clots. No oropharyngeal, hypopharyngeal
lesions or tumors was noted on endoscopic examination. Nasopharyngeal carcinoma with
right/left neck lymph node involvement was highly suspected. Nasopharyngeal biopsy was
done and pathology revealed undifferentiated carcinoma of nasopharynx.
Under the
impression of nasopharygeal carcinoma with right/ left neck metastasis, he was admitted
for further evaluation and treatment.
(Under the impression of nasopharygeal carcinoma with right/ left middle ear effusion, he
was admitted for myringotomy and ventilation tube insertion.)
八. 【Oral cancer】
Chief Complaint:
Right/Left neck mass noted for several months
A sore on the lip or in the mouth that does not heal.
A mass lesion or thickening on the lips or gums or in the mouth.
A white or red patch on the gums, tongue, tonsils, or lining of the mouth.
Bleeding, pain, or numbness in the lip or mouth.
Change in voice.
Loose teeth or dentures that no longer fit well.
Trouble chewing or swallowing or moving the tongue or jaw.
Swelling of jaw.
Sore throat or feeling that something is caught in the throat.
Present illness:
This 36 years-old male patient has habits of smoking and drinking for more than ten years.
He has history of 1) 過去病史 2) 過去病史. He denied history of human papillomavius
infection. He also denied exposure to direct or artificial sunlight over long periods of time.
This time, he was admitted due to 症狀＋時間. (A sore on the lip or in the mouth that
does not heal/ A mass lesion or thickening on the lips or gums or in the mouth/ A white or
red patch on the gums, tongue, tonsils, or lining of the mouth/ Bleeding, pain, or numbness
in the lip or mouth/ Change in voice/ Loose teeth or dentures that no longer fit well/
Trouble chewing or swallowing or moving the tongue or jaw/ Swelling of jaw/ Sore throat
or feeling that something is caught in the throat.)
According to himself, he has suffered from 症狀＋時間. Besides, 套用及帶入幾項以下
症狀(A sore on the lip or in the mouth that does not heal/ A mass lesion or thickening on
the lips or gums or in the mouth/ A white or red patch on the gums, tongue, tonsils, or
lining of the mouth/ Bleeding, pain, or numbness in the lip or mouth/ Change in voice/
Loose teeth or dentures that no longer fit well/ Trouble chewing or swallowing or moving
the tongue or jaw/ Swelling of jaw/ Sore throat or feeling that something is caught in the
throat/ Asymmetric swelling and sore throat with pain often radiating to the ipsilateral ear.)
He also complained of occasional halitosis or trismus. No known family member has
history of oral tumors or carcinoma.
九. 【Epiglottitis】
Chief Complaint:
Sudden onset of short of breath
Present illness:
This 45 year-old female with history of hypertension controlled with medical management
was admitted via ER due to sudden onset of shortness of breath.
According to the patient, she had a sore throat for about three days and even went to LMD
for help. Unfortunately, the symptoms didn’t improve. She felt shortness of breath since
this evening and also chilliness and fever. So she went to our ER for help.
Physical examination revealed shortness of breath and respiratory muscle use. We gave her
atrovent and bricanyl but the symptoms didn’t improve. Neck lateral X ray showed a
thumb sign. Bedside Npsocy was performed and showed infected and swollen epiglottis
with airway compromise. We performed nasal endoscopy and then transferred her to ICU.
Under the impression of acute epiglottitis, she was admitted to receive respiratory and
antibiotics therapies.
十. 【Deep neck infection】
Chief Complaint:
Right neck painful palpable mass and limitation for three days
Present illness:
This 36 year-old male with history of hypertension and type 2 DM not controlled with
medical management was admitted via ER due to palpable mass and movement limitation
of the right neck for three days.
According to the patient, he had the sore throat for about one week and even went to LMD
for help. Unfortunately, the symptoms didn’t improve. He felt pain and swelling in the
neck three days ago. The swelling and pain became worsen and worsen. He also felt
chilliness and fever. So he went to our ER for help.
Physical examination showed local heat and a palpable mass about 3*3cm in the right neck.
Oral showed bilateral tonsil injected with pus accumulation on NP. We performed
Nasopharyngealscopy, showing swelling of the right parapharyngeal wall and lingual tonsil
with vocal cord edema. We ordered a CT and found an abscess from SCM to supraclavicle.
Under the impression of deep neck infection, he was admitted and received I&D surgery.