Chief Complaint: Persistent hoarseness and throat discomfort
ASSESSMENT:
John Doe is a 45-year-old male with a history of chronic sinusitis, presenting with persistent hoarseness and throat discomfort for the past two months, with exam significant for mild erythema of the vocal cords, with scope demonstrating mild edema of the vocal cords, labs remarkable for normal thyroid function tests, and imaging showing no significant abnormalities. Clinical picture consistent with laryngopharyngeal reflux although vocal cord nodules are within the differential diagnosis.
PLAN:
- Initiate proton pump inhibitor therapy
- Recommend voice therapy
- Follow up outpatient with Otolaryngology - Head & Neck Surgery in 4 weeks
- Instructions for follow up placed in the patient's discharge paperwork, will task for follow up unless deemed as needed
- Discussed with Dr. Thomas Kelly, who is in agreement with the above
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 persistent hoarseness and throat discomfort for the past two months.
- Symptoms are worse in the morning and improve slightly 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.
