This is doctor xxxx ENT dictating operation report on xxxx last name xxxx 1st name xxxx, hospital xxxxx date of operation June x, xxxx.

PREOPERATIVE DIAGNOSES

1.    Nasal septal deviation with nasal obstruction.
2.    Chronic maxillary ethmoid and frontal sinusitis with chronic sinus origin headaches.
3.    Enlargement of inferior turbinates, bilateral.

POSTOPERATIVE DIAGNOSES

1.    Nasal septal deviation with nasal obstruction.
2.    Chronic maxillary ethmoid and frontal sinusitis with chronic sinus origin headaches.
3.    Enlargement of inferior turbinates, bilateral

SURGICAL PROCEDURE PERFORMED
 
1.    Nasal septoplasty.
2.    Bilateral endoscopic maxillary antrostomy with tissue removal from the maxillary sinus.
3.    Bilateral endoscopic total ethmoidectomy.
4.    Bilateral endoscopic frontal sinusotomy.
5.    Bilateral outfracture inferior turbinates.
6.    Above procedures were performed using optical image guidance.

INDICATIONS FOR SURGERY

The patient is a 61-year-old besiding history of chronic headaches, facial pain and symptoms of sinusitis who underwent medical treatment and had an abnormal sinus CT scan.   He has some septal deviation to the right side with nasal obstruction on the right and the CT shows near total opacification of the left maxillary sinus with some opacification within the tooth filled with some calcifications within the opacity suggesting possible impacted fungal growth.   There is also mucosal thickening opacity within the ethmoid sinuses more than left from the right and obstruction of the maxillary drainage on the right.   The frontal sinuses on both sides were involved with mucosal thickening in the area of the frontal recess.   The sphenoid sinus was clear.

DESCRIPTION OF OPERATION

The patient was taken to the main operating room under general endotracheal anesthesia.   The nose was packed with cotton pledgets soaked in Afrin solution and a throat pack was placed.   Bilateral greater palatine foramen injections were given for hemostasis.   The nasal septum was injected with lidocaine with epinephrine and the middle turbinate on the left side was injected as well.   Following the standard prep and draping the Medtronic optical image guidance system was calibrated and registered for use during the procedure.   The zero-degree nasal endoscope was used to inspect both sides of the nose.  The left side was more open so surgery was begun on this side 1st.   The middle turbinate had a small aerated concha and underwent of the CT scan there was some opacity within the concha.   Looking in the posterior part of the middle meatus there was a large accessory ostium into the maxillary sinus and some of the debried could be seen out in the maxillary sinus along with some purulent drainage.   The lateral nasal wall was injected with lidocaine with epinephrine for hemostasis, injecting in the area of the uncinate.   The middle turbinate was displaced medially and the antrum punch was used to incise through the lower attachment of the uncinate process and very thickened uncinate bone was reflected medially and then removed with the shaver.   This was then connected with the accessory ostium allowing better exposure into the maxillary sinus with some of the more solid impacted debris could be cleaned out of the maxillary sinus.   An opening was made in the ethmoidal bulla and the shaver was used to resect walls of the bulla along with both anterior and posterior ethmoid air cells and the inflamed mucosa of the nose cells.   The bone was noted to be somewhat thickened.  The standard landmarks of the middle turbinate medially tegmen superiorly and lateral nasal wall and the lamina laterally were identified.   The skull base was identified posteriorly and then followed anterior to the area of the frontal recess.   45 degrees nasal endoscope and 60 degrees curved shaver were used along with curved frontal suction curette and with the assistance image guidance of the ethmoid air cells were opened up bleeding into the area of the frontal recess and the frontal sinus was opened.   Bone fragments and mucosa were resected completely mucosal cover throughout the sinus as much as possible.   The nasal septoplasty was then performed making a vertical incision on the left side of the anterior portion of the cartilage, carrying it down to the plane beneath perichondrium, and a flap was elevated of the entire left side of the septal cartilage and bone.   A vertical incision was made, leaving an adequate caudal strut within the right side of the cartilage was exposed from that point posterior.   Options of the septal cartilage and bone were then resected leaving and adequate caudal support and portions of the maxillary crest bone that were very thick, were also removed.   There was a posterior septal spur that was resected.   The septal incision was then closed with interrupted 4-0 chromic followed by a 4-0 chromic mattress suture placed through into the septum for hemostasis.   The right side was then approached in the fairly thin middle turbinate was reflected medially and the lateral nasal wall was injected.   The uncinate process on this side was removed in a similar fashion to what was described on the left.   Although of the anatomy on this side was much more normal with no large accessory opening and no impacted debris within the sinus.   The natural ostium of the maxillary was widened with the shaver.   The 2nd CT scan did show involvement of the frontal sinus especially in the area of the frontal recess on the right side, so I went ahead and open into the ethmoidal bulla and removing the bony walls of the anterior and posterior ethmoid air cells.   Identifying the standard landmarks and then following the skull base anteriorly.   The frontal sinus was entered on the right side, as was described on the left.   Into the frontal approach the 45 degrees scope was utilized.   All of the small bone fragments were then removed and a prominent inferior turbinates on both sides were with outfracture of the turbinate bone with no submucosal resection.   Antibiotic ointment was then placed into the ethmoid cavity on both sides followed by a Gelfoam, and covered by Gel film.   A stent placed into the middle meatus and ethmoid region to keep the middle turbinate up against the septum.   Telfa gauze coated and antibiotic ointment was then placed on either side of the septum for hemostasis and the throat pack was removed.   He was awakened in the operating room where his extubated and transported to Recovery in stable condition.

This Dr. xxxxx in ENT dictating operation report on xxxxxxx xxxxxx last name xxxxxxx 1st name XXXX , middle, and Murray MARID off on

PREOPERATIVE DIAGNOSIS

1.    Nasal septal deviation with nasal obstruction.
2.    Bilateral chronic and recurring maxillary sinusitis.
3.    Hypertrophy of inferior turbinates.

POSTOPERATIVE DIAGNOSIS

1.     Nasal septal deviation with nasal obstruction.
2.    Bilateral chronic and recurring maxillary sinusitis.
3.    Hypertrophy of inferior turbinates

SURGICAL PROCEDURE PERFORMED

1.    Nasal septoplasty.
2.    Bilateral endoscopic maxillary antrostomy with tissue removal from the maxillary sinuses.
3.    Left submucous resection inferior turbinate.
4.    Right outfracture inferior turbinate.

INDICATIONS FOR SURGERY

The patient is a 29-year-old with a history of chronic nasal obstruction, blocking the right side of the nose with intermittent flare-ups of facial pain and sinusitis and abnormal sinus CT showing narrowing and blockage of the drainage of the maxillary sinuses on both sides.   She has prominent septal deviation to the right side and very large left inferior turbinate with thick intra turbinate bone.

DESCRIPTION OF OPERATION

The patient was taken to the main operating room under general endotracheal anesthesia.   The nose was packed with cotton pledgets soaked in Afrin solution and a throat pack was placed.   Lidocaine with epinephrine was injected in the nasal septum on both sides for hemostasis.   The following a standard prep and draping and the zero-degree nasal endoscope was used in the left side was approached 1st.   There was a concha of the middle turbinate on the left side and then had a fairly small air pocket, so I did not remove the lateral wall of the turbinate.   The middle turbinate was displaced medially to gain access to the area of the middle meatus where the lateral nasal wall in the area of the uncinate process was injected.   Access to the middle meatus was somewhat difficult because of the large size of the inferior turbinate, which on CT scan had very thick bone within the inside of the turbinate.   Before completion of the maxillary surgery on this side I went ahead  performed the nasal septoplasty in order to get better exposure to the middle meatus on the left.   A vertical incision was made on the left side of the septal cartilage anteriorly and could down to the plane beneath the perichondrium.   A submucosal flap was then elevated off the left side of the septal cartilage and bone extending posteriorly.   A vertical incision was made through the septal cartilage, leaving an adequate caudal strute anteriorly for support.   Mucosa on the right side of the vertical cartilage cut was then elevated back and abnormal portions of the septal cartilage with deviated way over the right side of the nose were then resected.  Inferiorly the mucosa was elevated off of the cartilage and bone portion of the septal ledge projecting to the right portions of the maxillary crest bone were resected.   Thickened posterior and superior septal cartilage and bone were removed as well as some thickening in the area of the mid portion of the septum representing a septal spur was removed.   The small tear was created on the mucosa of the septum on the right side but no involvement on the left.   Some flat segments of the septal cartilage and bone were placed back between the mucosal flaps for additional support and then the septal incision was closed with interrupted 4-0 chromic suture followed by a 4-0 chromic mattress suture placed through into the septum for hemostasis.   This allowed for marked improvement in exposure on the right side with more thin middle turbinate was reflected medially and the lateral nasal wall on the right was injected with local anesthetic.   The maxillary surgery was then performed starting on the right side.   The antrum punch was used to incise through the lower attachment of the uncinate process and the mid and upper portion was reflected medially with a blunt probe.   The shaver was used to remove the uncinate and expose the area of the natural ostium of the maxillary sinus.   There was some edema of the mucosa in the area of the natural ostium of a little bit of thickened secretion minimally cloudy but no purulent drainage noted.   Maxillary opening was widened with the shaver allowing good exposure out of the maxillary sinus.   The left side was then approached and the uncinate process was removed on this side as well, exposing the natural ostium and enlarging it in a similar manner to what was described on the right.   Both inferior turbinates were injected with local anesthetic in the left turbinate was approached 1st.   There was a large amount of compensatory enlargement of the turbinate due to the degree of the septal deviation and a good portion of the enlargement was bony thickening.   A vertical incision was made on the anterior aspect of the turbinate, dissected down to the turbinate bone and resected to the mucosa of the medial and lateral surface of the turbinate bone.   The bone was so thick that had to use a chisel to fracture along the superior portion of the turbinate attachment and then of very thick piece of turbinate bone was removed.   The removing the turbinate bone, little bit of the mucosa of the mid portion of the turbinate stated apparent to the bone in created there in the middle portion of the surface mucosa.   This created some roughened edges of the mucosa but it was able to smooth down with the shaver removing segments of the mid portion of the turbinate mucosa preserving the anterior portion.   On the right side of the extreme anterior part of the turbinate was not very prominent and there was some prominence of the posterior portion of the structure, so I used Freer elevator and outfractured the mid and posterior portion of the turbinate without making any incisions on the through that mucosa.   Antibiotic ointment was then placed in the middle meatus on both sides.   Followed by a stent of Gelfoam covered with gel film that was placed between the middle turbinate and lateral nasal wall to adhesions.   Telfa gauze coated, antibiotic ointment was then placed on either side of the septum for hemostasis.   The throat pack was removed.   She was awakened in the operating room where she was extubated and transported to Recovery in stable condition.

This is doctor XXXXX dictating discharge summary on Willie, frank Crosby patient comes XX:XX date of admission May X, XXXX date of discharge May XX, XXXX. Subheading.

DISCHARGE DIAGNOSES

1.    Systolic congestive heart failure, acute upon chronic, ejection fraction 30%.
2.    Moderate bilateral pleural effusion.
3.    Bibasilar atelectasis versus bibasilar infiltrates per CT scan of the chest.
4.    Lymphadenopathy.
5.    Fatigue and malaise.
6.    Mitral valve regurgitation, moderate.
7.    Remote history of a hemorrhagic stroke without significant residual neurological deficits.
8.    Acquired and equal length of the leg.
9.    Status post total hip arthroplasty in the past.

CONSULTATIONS

Dr. XXXX , cardiology.  Dr. XXXXXX ,  pulmonary.


PRINCIPLE PROCEDURES

1.    Echocardiogram.
2.    Venous Doppler ultrasound of lower extremities.
3.    CT scan of the chest/CT pulmonary angiogram.

REASON FOR ADMISSION

Mr. Crosby is a 79-year-old black male who presented to the office with progressive shortness of breath, onset 2-3 weeks ago, occasional cough with minimal sputum production, hoarseness for the previous 3-4 months.   On the date prior to presentation the patient slept sitting up on the chair all night because of shortness of breath seemed worse when he lied down.  He had also noted some blood in the sputum for several days but not recently.   Admitted for further evaluation and management with appropriate consultations.

HOSPITAL COURSE

Following admission baseline lab work included a CBC, CMP, TSH, D-dimer, BNP, ABGs, EKG and chest x-ray as well as CT scan of the chest per PTE protocol.   Metabolic panel was within normal limits.   BNP was elevated to 1040.   D-dimer elevated to 791.   Cardiac enzymes as well as TSH well within normal limits.   CBC was normal as well as urinalysis.  Drug screen was positive for cannabinoids.  ABGs showed a pH of 7.45, PCO 222.0, pO2 90, bicarbonate 15.0, and oxygen saturation 98%.   Chest x-ray showed a bilateral basilar pleural effusions.  Venous Doppler ultrasound of lower extremities was remarkable for the deep vein thrombosis.   CT scan of the chest per PTE protocol showed no evidence of pulmonary embolus, there was mediastinal and hilar adenopathy.   In addition to a small bilateral pleural effusions and bilateral infiltrates and/or atelectasis.   With these findings, pneumonia was suspected and the patient was initiated on antibiotics empirically.   Consultation was obtained with pulmonary and the patient was seen by Dr. XXXX, and with the diagnosis of pneumoniae was not and obtained in favour of systolic congestive heart failure, acute upon chronic.   Consultation was obtained cardiology, Dr. XXXX and associates.  Medical management was recommended, to include diuretics, in addition to Coreg, angiotensin receptor blockers in addition to Aldactone.   Cardiac ischemic workup recommended for later on outpatient basis.   Supplemental nasal oxygen provided as needed.   Continued on IV Levaquin and p.o. Zithromax until pneumonia completely ruled out.   With management of congestive heart failure patient's symptoms of dyspnea/shortness of breath and cough progressively improved to complete resolution.   Start generate with above management the patient progressively improved to baseline status.   Echocardiogram report as recorded, with an ejection fraction of 30%, and findings consistent with systolic congestive heart failure, mild to moderate mitral regurgitation.   Also noted to have mild hypokalemia which was corrected.   By discharge date, patient was totally asymptomatic and by this time it was agreed that patient could be safely discharged home and continued on outpatient care and followup.

DISCHARGE MEDICATIONS

1.    Cozaar 100 milligrams p.o. daily.
2.    Coreg 6.25 milligrams p.o. b.i.d.
3.    Lasix 40 milligrams, half a tablet p.o. q.a.m.
4.    Spironolactone 25 milligrams p.o. q.a.m.

 FOLLOW UP APPOINTMENTS

1.    Follow up appointment with Dr. XXXXXXX in 3-4 weeks after discharge.
2.    Follow up appointment with me in 4 weeks, sooner should there be any problems.

DIET

Low-salt, low-cholesterol, low-fat diet.

ACTIVITY

Gradually increase as tolerated.  Regular walking exercises recommended.  He is safety measures and health maintenance discussed.   No smoking.

CONDITION AT DISCHARGE

Improved, stable and satisfactory.

Hypothyroidism with history of thyroiditis

VITAL SIGNS:  Temperature 97.3, pulse 76, respiration 16, and BP 152/104.  Weight 130 pounds.
GENERAL:  No acute distress.  A and O x3.
HEENT: Normocephalic and atraumatic.  Extraocular muscles are intact.  Pupils are equal, round, reactive to light, and accommodation.  Oropharynx is nonerythematous.  Mucous membranes are moist.
NECK: Supple.  I do not appreciate any thyroid nodules or thyromegaly on examination.
RESPIRATORY:  Nonlabored breathing.
PSYCHIATRIC:  Good affect.

 1.    Hypothyroidism with history of thyroiditis.  I have discussed the case with Dr. Christ and at this time we will not be performing a fine-needle biopsy.  However, I will be referring the patient to endocrinology.  I am ordering monthly TSH and free T4 and I am ordering thyroid antibodies and I am also ordering a thyroid radionuclide study as per radiology suggestion.  The patient is to follow up in 4 weeks or p.r.n. sooner.  I have also had attempted through for the patient' to ears, nose, and throat, Dr. Kimball at this time.  He states that the patient should be seen by endocrinology prior to seeing the ears, nose, and throat.  Therefore, I have referred the patient to endocrinology. We are awaiting the patient's appointment.
 

2.    Nausea.  I am going to be recheck a barium swallow study on the patient.
 

3.    Bilateral knee pain, left knee x-rays came back negative.  They showed no abnormalities.  I had prescribed the patient Tylenol Arthritis and Ultram.

The patient verbally understood all instructions at this time of visit.  She is to follow up in 4 weeks or p.r.n. sooner.

The above SOAP note was discussed with Dr. Accamma Joy who agrees with the above assessment and plan/