smoh/medical-transcriptions huggingface dataset:
Tonsillectomy & Adenoidectomy - 2  ( ENT - Otolaryngology)
Description:  Tonsillectomy & adenoidectomy.  Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.  

PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:,  Under general anesthesia with an endotracheal tube, the patient was placed in supine position.  A mouth gag was inserted and suspended from Mayo stand.  Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate.  The adenoid area was inspected.  The adenoids were small.  The left tonsil was grasped with a tonsil tenaculum.  The tonsil was removed with the Gold laser.  The apposite tonsil was removed in a similar manner.  Hemostasis was secured with electrocautery.  Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline.  The patient tolerated the procedure well and left the operating room in good condition.
Tonsillectomy & Adenoidectomy - 1   ( ENT - Otolaryngology)
Description:   Tonsillectomy and adenoidectomy.  McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.

PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:,  General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror.  The adenoid tissue was fulgurated with the suction Bovie set at 35.  The catheters and the dental gauze roll were then removed.  The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine.  Using the radiofrequency wand, the tonsils were ablated bilaterally.  If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9.  The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
Tonsillectomy  ( ENT - Otolaryngology)
Description:  Tonsillectomy.   Tonsillitis.  McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. 

PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS:  ,Tonsillitis.,PROCEDURE PERFORMED:  ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil.  The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.  The right tonsil was grasped with the tenaculum and retracted out of its fossa.  The anterior tonsillar pillar was incised with the #12 knife blade.  The plica semilunaris was incised with the Metzenbaum scissors.  Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied.  The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described.  By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil.  The pack was removed and bleeding was controlled with the suction Bovie unit.  Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs.  The catheters were then removed.  The nasal passages and oropharynx were suctioned free of debris.  The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
Tonsillectomy & Adenoidectomy  ( ENT - Otolaryngology)
Description:  Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.

PREOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:,  Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:,  General.,HISTORY: , The patient is 5-1/2 years old.  She is here this morning with her Mom.  She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well.  At the office we saw the tonsils were very big.  There was a rock in the right ear and it was very deep in the canal, near the drum.  We will remove the foreign body under the same anesthetic.,PROCEDURE:,:  Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B.  I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum.  On the right side, I took out some impacted wax and removed the rock with a large suction.  It was actually resting on the surface of the drum but had not scarred or damaged the drum.  The drum was intact with no evidence of middle ear fluid.  The microscope was set aside.  Afrin drops were placed in both nostrils.  The neck was gently extended and the Crowe-Davis mouth gag inserted.  The tonsils and adenoids were very large.  The uvula was intact.  Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx.  Tonsillectomy accomplished by sharp and blunt dissection.  Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine.  Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds.  Sponge is removed from the nasopharynx.  The suction electrocautery was used for pinpoint hemostasis on the adenoid bed.  We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices.  The nose and throat were then irrigated with saline and suctioned.  Excellent hemostasis was observed.  An orogastric tube was placed.  The stomach found to be empty.  The tube was removed, as was the mouth gag.  Sponge and needle count were reported correct.  The child was then awakened and prepared for her to return to the recovery room.  She tolerated the operation excellently.
Status Post Tympanoplasty   ( ENT - Otolaryngology)
Description:  The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago.  

The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.
Status Post T&A  ( ENT - Otolaryngology)
Description:  Underwent tonsillectomy and adenoidectomy two weeks ago. 

SUBJECTIVE:,  A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  Also, I cleaned out his maxillary sinuses.  Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  He finished up his Augmentin, by a day or two later he was off the Lortab.  Mom has not noticed any unusual voice change.  No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  He has not had any nasal discharge or ever had any bleeding.  He seems to be breathing better.,OBJECTIVE:,  Exam looks good.  The pharynx is well healed.  Tongue mobility is normal.  Voice sounds clear.  Nasal passages reveal no discharge or crusting.,RECOMMENDATION:,  I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  It is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well.  There are no other restrictions or limitations.  I told Mom, I had written to Dr. XYZ to let her know of the findings.  The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed.  He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.
Sinus problems - Consult  ( ENT - Otolaryngology)
Description:  Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.

CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0).  Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:,
SOM - Serous Otitis Media  ( ENT - Otolaryngology)
Description:  A sample note on serous otitis media

Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay.  Children begin to speak some words by 18 months.  Children with fluid in both ears can show significant delay in their use of language.  In addition, young children learn to pronounce words by hearing them spoken.  When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears.  Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear.  Most children will have at least one ear infection before the age of four.,With treatment, the ear infections clear up promptly.  Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms.  Therefore, it is essential that ear infections be rechecked after initial treatment.  Usually, the presence of fluid results in a "mild conductive hearing loss." This could be as much as 30% hearing loss overall.  After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised.  This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays.  If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated.  The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardum itself under the surgical microscope.  Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted.  The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia.
Septoplasty & Turbinectomy  ( ENT - Otolaryngology)
Description:  Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.

OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room.  After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray.  After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium.  After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate.  A 45-degree forceps then used to open up the maxillary sinus.  There was some prominent tissue and just superior to this, the anterior ethmoid was opened.  The 45-degree forceps was then used to open the maxillary sinus ostium.  This was enlarged with backbiting rongeur.  After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa.  After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate.  There was noted to have prominence in the anterior ethmoidal area.  This was then opened with 45-degree forceps.  This mucosa was then removed from the anterior area.  The maxillary sinus ostium was then opened with 45-degree forceps.  Tissue was removed from this area.  This was sent as right maxillary mucosa.  After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus.  Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally.  This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction.  After this was completed, a septoplasty was performed.  The incision was made with a #15 blade Bard-Parker knife.  The flap was then elevated, overlying the spur that was protruding into the right nasal cavity.  This was excised with a #15 blade Bard-Parker knife.  The tissue was then laid back in position.  After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx.  , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon.  The patient was then awakened and taken to recovery room in good condition.
Progress Note - Supraglottitis  ( ENT - Otolaryngology)
Description:  Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.

HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008.  Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED:  ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver.  No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION:  ,1.  Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2.  Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3.  Hypercholesterolemia.,4.  History of anxiety.,5.  History of coronary artery disease.,6.  Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X.  Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation.  I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.
Sample Normal Exam - ENT  ( ENT - Otolaryngology)
Description:  An example of normal ENT exam.

NASAL EXAM: , The nose is grossly in the midline with no evidence of fractures or dislocations.  The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates.  There is no pus or polyps in the nose on anterior rhinoscopy.  The airway appears adequate.  No external valve prolapses are observed.,THROAT EXAM: , The oral cavity is clear.  The tongue is clear with no lesions noted and with good symmetrical movement.  The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection.  Palate is clear.  The tonsils are not prominent.,No overt neoplasms in the mouth are noted.  Lips are clear.  The voice is adequate no deficits or hoarseness.  The saliva is clear.,EARS:  ,Canals are clear.  Eardrums are clear, moving on insufflation and swallowing.  No discharge is noted in the canals.  Hearing appears adequate in normal tonal conversations.,NECK EXAM: , Neck is supple with no palpable masses.  No lymphadenopathy.  The thyroid gland is not palpable.  The trachea is in the midline.  The parotid and submaxillary glands are not enlarged, are symmetrical and are not tender.  The neck movement is adequate.,GROSS NEUROLOGICAL EXAM: , Cranial nerves II-XII are intact.  Extraocular movements are full with no restrictions.  Patient is alert and responsive.,EYE EXAM: , Sclerae are clear.  Conjunctivae are clear.  Pupils respond symmetrically to light.  Extraocular movements are complete and full.
Postop Parathyroid Exploration & Parathyroidectomy  ( ENT - Otolaryngology)
Description:  This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night. 

SUMMARY:  ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.  She put out 1175 mL of urine since surgery.  Her incision looks good.  IV site and extremities are unremarkable.,LABORATORY DATA:  ,Her calcium level was 7.5 this morning.  She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:,  I will heparin lock her IV, advance her diet, and ambulate her.  I have asked her to increase her prednisone when she goes home.  She will double her regular dose for the next five days.  I will advance her diet.  I will continue to monitor her calcium levels throughout the day.  If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow.  She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill.  Her final calcium dosage will be determined prior to discharge.  I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.
Parotidectomy  ( ENT - Otolaryngology)
Description:  Parotidectomy procedure
ORIF Facial Fractures - Followup  ( ENT - Otolaryngology)
Description:  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.

Mr. ABC was transferred to room 123 this afternoon.  We discussed this with the nurses, and it was of course cleared by Dr. X.  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening.  This will make it much easier for him to swallow.  This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today.  He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place.  It is a size 8 Shiley nonfenestrated.  He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.