Otorhinolaryngologist (ENT Specialist) Template

Sinus template

A professional Otorhinolaryngologist (ENT Specialist) template for healthcare professionals.

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Specialty

Otorhinolaryngologist (ENT Specialist)

Used

7 times

Type

Note

Last edited

6/16/2025

Created by

John Lee

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About this template

This sinus template is designed for otorhinolaryngologists (ENT specialists) to document patient visits related to sinus issues. It includes sections for subjective and objective findings, past medical history, and a detailed plan for treatment. The template is ideal for capturing comprehensive information about sinus conditions, including chronic sinusitis and nasal polyps. It facilitates thorough documentation of physical examinations and investigations, such as CT scans, and supports the creation of a tailored treatment plan. This template is particularly useful for ENT specialists managing complex sinus cases and planning surgical interventions.

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We were pleased to see this patient today. ID: 45 year old male **Subjective:** Reason for Referral: Chronic sinusitis with nasal obstruction History of Present Illness: The patient reports a 6-month history of nasal congestion, facial pressure, and postnasal drip. Symptoms have worsened over the past month, with occasional headaches. Relevant Past Medical History: - Asthma: Yes - Environmental Allergy: Tested (Positive for dust mites) - ASA Sensitivity: No - Previous Sinonasal Surgery: Yes (Surgery Date: 15 March 2020) Medications: Fluticasone nasal spray, Montelukast Medication Allergies: No known drug allergies Social History: - Smoking: Ex-smoker (10 pack-year history) - Alcohol: Social **Objective:** Physical Examination: - Ears: EACs and TMs within normal limits - Oral Cavity: Within normal limits - Oropharynx: Within normal limits - Septum: Deviation to right - Flexible Endoscopy: - Polyps: Right Grade: 2, Left Grade: 1 - Mucosa: Moderate Inflammation - Purulence: Yes - Nasopharynx: Normal - Larynx: Normal, mobile vocal cords - Hypopharynx: Normal, no lesions seen - Other Comments: Mild crusting observed - Neck: No cervical adenopathy The remainder of the head and neck examination was unremarkable. Investigations: - Imaging: CT - Region: Sinus **Assessment:** Summary: The patient presents with chronic sinusitis with nasal polyps and moderate inflammation, likely exacerbated by environmental allergies and a history of asthma. **Plan:** We have recommended bilateral endoscopic sinus surgery with possible septoplasty. The benefits, risks—including risks of general anesthesia, infection, bleeding, <1% risk of eye/brain injury, septal perforation, and potential need for revision surgery—were discussed. Surgery is scheduled for the next available date. Thank you for asking us to see this patient. Please let us know if you have any questions. Sincerely, Dr. John Smith for Consultant Dr. Thomas Kelly