Otolaryngology Documentation Template

Chief Complaint: Ongoing hoarseness and throat irritation
ASSESSMENT:
John Doe is a 45-year-old male with a history of chronic sinusitis, presenting with ongoing hoarseness and throat irritation for the past two months. Examination reveals mild erythema of the vocal cords, with scope findings showing mild edema of the vocal cords. Laboratory tests indicate normal thyroid function, and imaging shows no significant abnormalities. The clinical presentation is consistent with laryngopharyngeal reflux, although vocal cord nodules remain a differential diagnosis.
PLAN:
- Start proton pump inhibitor therapy
- Suggest voice therapy
- Schedule follow-up with Otolaryngology - Head & Neck Surgery in 4 weeks
- Follow-up instructions included in the patient's discharge paperwork, with a task for follow-up unless otherwise needed
- Discussed with Dr. Thomas Kelly, who concurs with the plan
SUBJECTIVE:
History of Presenting Illness:
John Doe is a 45-year-old male presenting with the above chief complaint for which Otolaryngology is consulted.
- The patient reports ongoing hoarseness and throat irritation for the past two months.
- Symptoms are worse in the morning and slightly improve with hydration.
- The patient has tried over-the-counter throat lozenges with minimal relief.
- Symptoms have gradually worsened over the past two months.
- No previous episodes of similar symptoms.
- The hoarseness affects the patient's ability to communicate effectively at work.
- Associated symptoms include mild throat clearing and occasional cough.
- Past medical history includes chronic sinusitis.
- Social history: The patient is a non-smoker and does not consume alcohol.
- Family history: No significant ENT-related conditions.
- No significant exposure history.
- Immunizations are up to date.
OBJECTIVE:
Physical Examination:
Exam Exceptions, Pertinent +/-
- Mild erythema of the vocal cords noted
Exam with Corrections above:
General: No acute distress 
Voice: Phonation clear and strong 
Head & Face: Normocephalic, atraumatic 
Eyes: EOMI, PERRL, no APD, moist conjunctivae 
Ears: Auricles normal appearance. No masses, lesions or scars. EACs patent AU. 
Nose: No external abnormality. Septum non-deviated. Turbinates non-erythematous, non-swollen, no pus. No masses, no polyps. Mucosa healthy. 
Oral Cavity: Mucosa no lesions. Lips no masses or lesions. Oral tongue no masses or lesions, normal mobility. Dentition good. FOM without abnormality. 
Oropharynx: Soft palate no masses or lesions, normal elevation. Tonsils/fossae without abnormality. Symmetric posterior pharynx. 
Neck: Soft/flat. No cervical, supraclavicular, or auricular LAD. Trachea midline. 
Laryngeal framework palpable. Thyroid no masses or fullness. 
PULM: No IWOB 
CV: RR, pulse without abnormality 
ABD: Soft, NT/ND
Skin: No lesions 
MSK: Moves extremities x4 
NEURO: Cranial Nerves: II - XII grossly intact, HB 1/6 bilaterally 
Flexible Fiberoptic Laryngoscopy with corrections below:
After obtaining verbal consent, the nasal passage(s) were prepared with a topical mixture of 4% topical lidocaine and 0.05% oxymetazoline. Next, the flexible endoscope was inserted into the left naris, which was grossly normal. Nasopharynx grossly normal without mass or lesion. Posterior pharynx symmetric without mass or lesion. The base of tongue is normal and symmetric. Vallecula is clear. The epiglottis and aryepiglottic folds are crisp and without mass or lesion. The supraglottic inlet is unobstructed. The true vocal folds are fully mobile and symmetric without mass or lesion. The visualized subglottis is patent. The pyriform sinuses are clear and without pooling of secretions. The patient tolerated the procedure well without complication.