ENT Operative Medical Note Sample Format #1
BRIEF HISTORY: The patient is a (XX)-year-old female with a 6-month history of sore throat and a 3-month history of left otalgia who presented to the office with a lesion in the left base of the tongue. Intraoperative biopsy was concerning for carcinoma but without exact diagnosis. Decision was made to take her to the operating room for direct laryngoscopy with biopsy and esophagoscopy. The risks and benefits of the procedure were explained to the patient and she agreed to proceed.
PREOPERATIVE DIAGNOSIS: Left base tongue mass.
POSTOPERATIVE DIAGNOSIS: T4N0MX squamous cell carcinoma of the left base of the tongue.
PROCEDURES PERFORMED:
1. Direct laryngoscopy with biopsy.
2. Esophagoscopy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 5 mL.
SPECIMEN: Left base of the tongue for frozen and permanent.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was turned.
The procedure began with a direct laryngoscopy. There was a large lesion on the left base of the tongue, which had some minimal extension on the left pharyngeal wall and tonsil. No other lesions were noted in the vallecula, epiglottis, aryepiglottic folds, piriform sinuses or true or false vocal folds. Multiple biopsies were sent for frozen and permanent pathology. The frozen section came back as squamous cell carcinoma.
The laryngoscope was then removed. Esophagoscope was then used to evaluate the esophagus for concurrent tumors. The esophagoscope was placed in the posterior pharynx, hypopharynx, and esophagus. It was passed all the way down to the level of stomach. The esophagoscope was withdrawn with attention to all of the mucosal walls of the esophagus. There were no lesions or masses noted.
The esophagoscope was then removed. At that point, the procedure was terminated. The patient was awoken from the general anesthesia, extubated and sent to postanesthesia care unit in stable condition.
ENT Operative Medical Note Sample Format #2
PREOPERATIVE DIAGNOSIS: Chronic tonsillitis.
POSTOPERATIVE DIAGNOSIS: Chronic tonsillitis.
PROCEDURE PERFORMED: Tonsillectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Zero.
SPECIMENS: Bilateral tonsils.
DETAILS OF PROCEDURE: The patient was taken to the operating room. He was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty.
The table was turned. A Crowe-Davis mouth gag was then placed in the oral cavity to visualize the tonsils. The patient had large tonsils bilaterally. Procedure began with the right tonsil being grasped with a tonsil clamp. Tonsil was medialized, and Bovie cautery was used to excise the tonsil from its tonsillar fossa. Small vessels were identified and cauterized. Tonsils were removed and sent for permanent pathology. There was no evidence of bleeding. The left tonsil was then grasped with a tonsil clamp. The tonsil was then medialized. Again, Bovie cautery was used to find the tonsillar fossa. Blunt dissection was used to identify vessels for cauterization. The tonsil was then removed and sent for permanent pathology. There was no evidence of bleeding.
Red rubber catheter was then placed through right nostril and out the oral cavity. This allowed visualization of the nasopharynx with the mirror. There was no evidence of adenoid hypertrophy. The red rubber catheter was then removed. Copious amounts of normal saline were then used to irrigate the oral cavity and oropharynx. Again, there was no evidence of bleeding. An oral gastric tube was then used to decompress the contents of the stomach.
The procedure was then terminated. The patient was awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
ENT Operative Medical Note Sample Format #3
PREOPERATIVE DIAGNOSIS: Graves’ disease with Graves’ ophthalmoplegia.
POSTOPERATIVE DIAGNOSIS: Graves’ disease with Graves’ ophthalmoplegia.
PROCEDURE PERFORMED: Endoscopic orbital medial wall decompression.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 100 mL.
SPECIMEN: None.
DETAILS OF PROCEDURE: The patient was taken to the operating room and placed in supine position on the operating table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty.
The procedure began with injection of 6 mL of 1% lidocaine with 1:100,000 epinephrine into the uncinate and middle turbinate. Afrin-soaked nasal pledgets were placed in the nares bilaterally. After allowing time for anesthesia and decongestion, the patient was prepped and draped in a routine fashion. The Afrin-soaked nasal pledgets were removed. The procedure began with identification of the uncinate after medialization of the middle turbinate. The uncinate was taken down with the pediatric back biter. A 4-mm Straightshot microdebrider was then used to remove the rest of the uncinate. This allowed visualization of the natural os of the maxillary sinus. This was enlarged with the Straightshot microdebrider posteriorly to the posterior antral wall and superiorly to the inferior floor of the orbit.
Anterior and posterior ethmoidectomy were then performed with the Straightshot microdebrider. The tissue was removed along the medial wall of the orbit up to the skull base. A small dehiscence in the lamina papyracea was identified and a sinus seeker was used to infracture the bone of the lamina papyracea. This infracture was carried inferiorly from the medial border of the inferior floor of the orbit superiorly to the skull base, posteriorly to the annulus of the orbit and anteriorly to the nasolacrimal canal. Once the lamina papyracea was removed, a sickle knife was then used to incise the periorbita.
Three incisions were performed from posterior to anterior superiorly in the midline and on the inferior exposed portion of the periorbita. Endoscopic scissors was used to incise the anterior and posterior periorbita and the periorbita was removed. This allowed excellent decompression of the orbital fat into the sinus cavity. Hemostasis was then obtained with irrigation with warm saline. Floseal, approximately 5 mL, was then placed in the nasal cavities for completion of hemostasis. The nasopharynx was suctioned. There was no evidence of further bleeding.
At that point, the procedure was terminated. The patient was then awakened from general anesthesia, extubated and sent to the postanesthesia recovery unit in stable condition.
ENT Operative Medical Note Sample Format #4
PREOPERATIVE DIAGNOSIS: Laryngeal leukoplakia bilaterally.
POSTOPERATIVE DIAGNOSIS: Hyperkeratosis of the vocal folds.
PROCEDURE PERFORMED: Microsuspension direct laryngoscopy with biopsy using operating microscope.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Zero mL.
DETAILS OF THE PROCEDURE: The patient was taken to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by anesthesiology service without difficulty. The table was turned. The surgery began with direct laryngoscopy using Dedo laryngoscope. There were no lesions or masses noted in the base of tongue, vallecula, epiglottis, bilateral piriform sinuses, aryepiglottic folds, or false vocal folds. There was thickening with some whiteness to the vocal folds bilaterally.
The patient was then placed in suspension. Operating microscope was brought into the field. Under microscopy, the right and left vocal folds were biopsied and sent for frozen diagnosis. The frozen diagnosis came back as hyperkeratosis. No other lesions or masses were noted. The operating microscope was then removed. The Dedo laryngoscope was taken out of suspension and removed. The teeth were examined.
The procedure was then terminated, and the patient was awoken from general anesthesia. There were no complications during the procedure.
ENT Operative Medical Note Sample Format #5
PREOPERATIVE DIAGNOSIS: Facial lipoma.
POSTOPERATIVE DIAGNOSIS: Facial lipoma.
PROCEDURE PERFORMED: Excision of recurrent facial lipoma, right face.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 20 mL.
SPECIMENS: Right facial lipoma.
FINDINGS: The patient had a large 4 cm lipoma overlying the temporalis muscle of the right face. This lesion had 2 large cystic components.
DETAILS OF PROCEDURE: The patient was taken to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was turned and approximately 7 mL of 1% lidocaine with 1:100,000 epinephrine mixed with 0.25% Marcaine was injected.
An incision line just anterior, slightly into the scalp and the lateral face. After allowing time for decongestion, an incision was made in this site approximately 4 cm in length, down through the subcutaneous tissues into the subcutaneous fat. Dissection was carried down with blunt scissors dissection and bipolar cautery down to the temporalis fascia. The mass was then identified on top of the temporalis fascia. Blunt dissection with scissors and bipolar cautery were carried beneath the mass along the temporalis fascia medially to the lateral border of the lateral orbital rim.
Dissection was then carried superiorly and inferiorly to liberate this mass from the deep tissues. Dissection was then carried over the superficial portion of the mass. Careful dissection was used to make sure we are on the capsule of the mass to protect the frontal branch of the fascial nerve. Nerve stimulation was used throughout the entire case and the nerve never stimulated. The nerve was never visualized throughout the case. Dissection was carried anteriorly along the superficial part of the capsule to the lateral wall of the orbit. The mass then was released from the surrounding tissues and sent for permanent pathology. The size of the mass was 4 cm x 4 cm.
The wound was then thoroughly irrigated. Hemostasis was obtained with bipolar cautery. The wound then was sterilely irrigated. There was no evidence of bleeding. Small Penrose drain was placed and secured to the skin with 5-0 Prolene stitch. The wound was then closed in layered fashion. Deep layers were reapproximated with 4-0 Vicryl suture and 5-0 Monocryl running subcuticular closure was then performed. Dermabond was used to reapproximate the skin. Dressing was placed once the Dermabond was dry. Paper tape was used to secure the dressing. The surgery was completed. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
