Re: ENT Clinic Appointment On 1 November 2024
I am writing to summarise what we discussed at your appointment today about your persistent blocked nose and difficulty breathing through your right nostril.
Diagnosis
1. Chronic Rhinosinusitis with Nasal Polyps
2. Deviated Nasal Septum
Management Plan
1. Functional Endoscopic Sinus Surgery (FESS) with Septoplasty and Turbinate Reduction
General Anaesthetic
Day Case
Approximate Duration: 2 hours
2. Prescribed a course of Fluticasone Propionate nasal spray, two sprays in each nostril twice daily for 3 months post-surgery.
3. Referral to Allergy Clinic for further investigation of potential environmental triggers.
4. Follow-up appointment scheduled in 6 weeks post-surgery for review.
During your visit, we discussed the following.
You reported a history of persistent nasal congestion, particularly on the right side, for the past two years. You also experience a reduced sense of smell and occasional clear nasal discharge. You have tried over-the-counter nasal decongestants without significant long-term relief.
Your Medical History
You have a history of seasonal allergies, managed with antihistamines as needed.
Your Medications
Cetirizine 10mg once daily as needed for allergies.
Allergies
Penicillin (rash)
Dust mites (sneezing, runny nose)
Social History
You are a non-smoker. You consume alcohol occasionally, approximately 2 units per week. You work as an accountant. You live with your spouse in a house with no known mould issues.
On Examination
Ears: Tympanic membranes intact and mobile bilaterally. No signs of infection or effusion.
Oral Cavity And Throat: Oropharynx clear, no tonsillar hypertrophy. Posterior pharyngeal wall unremarkable.
Neck: No palpable lymphadenopathy or masses. Thyroid non-tender and normal in size.
Anterior Rhinoscopy: Significant deviation of the nasal septum to the right, obstructing the right nasal airway. Bilateral nasal polyps noted, larger on the right, partially obscuring the middle meatus.
Flexible Nasendoscopy: Confirmed septal deviation and bilateral nasal polyps, with evidence of mucosal oedema and purulent discharge in the right middle meatus. Postnasal space clear. Larynx appears healthy with symmetrical vocal cord movement.
Investigations And Results
We discussed the results of your recent CT scan of the paranasal sinuses, which showed extensive mucosal thickening and opacification of the ethmoid and maxillary sinuses bilaterally, consistent with chronic rhinosinusitis, along with significant septal deviation and nasal polyps.
Impression
You have chronic rhinosinusitis with nasal polyps and a deviated nasal septum. This is causing your persistent nasal blockage, reduced sense of smell, and difficulty breathing through your nose. We discussed that the polyps are inflammatory growths within the sinuses and nose.
Discussion About Surgery
We discussed the option of Functional Endoscopic Sinus Surgery (FESS) with Septoplasty and Turbinate Reduction, which is a procedure to open up your sinus drainage pathways, remove the polyps, straighten your nasal septum, and reduce the size of your nasal turbinates.
Anaesthetic: General Anaesthetic
Admission: Day Case
Approximate Duration: 2 hours
Alternatives Discussed: Medical management with steroid nasal sprays and saline rinses, which you have already tried with limited success. The option of not proceeding with surgery was also discussed, which would likely result in continued symptoms.
The risks and complications we discussed were:
- Bleeding, usually minor but occasionally requiring further intervention.
- Infection, which would be treated with antibiotics.
- Changes in sense of smell, which can occasionally occur.
- Recurrence of polyps, which can happen despite surgery.
- Very rarely, damage to the eye or brain due to the proximity of the sinuses.
We discussed that you would likely require a week to ten days off work for recovery, and that you should avoid strenuous activities during this time. You will receive detailed post-operative instructions.
What You Can Do To Help
It is important to continue using the Fluticasone Propionate nasal spray as prescribed after surgery to help prevent polyp recurrence. Regular nasal douching with saline solution will also be beneficial for nasal hygiene and to aid healing.
When To Seek Urgent Help
If you experience severe bleeding from your nose, a sudden change in vision, severe headache, or a high fever after surgery, please contact the ENT ward immediately or attend your nearest emergency department.
Next Steps
Your surgery date will be arranged, and you will receive a letter with the details. We will see you back in the clinic approximately 6 weeks after your surgery to assess your recovery and discuss the allergy clinic referral.
Please do not hesitate to contact me if you have any questions or require further information.
Please note this letter has been transcribed by Heidi Health, an AI transcribing tool, and has been checked for errors.
(Write in the second person throughout, using "you" and "your" in a warm, clear, and professional tone. Do not use the patient's name anywhere in the letter. Where the clinician has used a medical term, only include a plain-English explanation if the clinician also used plain-English wording in the transcript. Do not invent definitions. Only include examinations that the clinician explicitly stated were performed. Do not infer or add examination findings. Do not write "normal", "unremarkable" or "nil of note" unless those exact findings were stated. Do not invent, infer, or assume any clinical details.)
(If the contextual notes indicate the patient is a child who attended with a parent, guardian, or other adult, address the letter to that adult. Refer to the child as "your son", "your daughter", or "your child" as appropriate. Document the history as having been provided by the accompanying adult. Do not write as though the history was provided by the child themselves.)
Re: ENT Clinic Appointment On [Date of the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit the date and write "Re: ENT Clinic Appointment" only.)
I am writing to summarise what we discussed at your appointment today about [the topic or main reason for the consultation as stated by the clinician]. (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit the topic description and write the opening line without it.)
Diagnosis
[A numbered list of diagnoses or working clinical problems discussed during the consultation, drawn from anywhere in the transcript, contextual notes, or clinical note including the clinician's impression, the discussion of the problem, or the reason for attendance] (Always include this section. Never invent or infer a diagnosis. If no diagnosis or working problem can be identified from the source material, else write: "Working diagnosis not stated." Present each diagnosis or working problem as a separate numbered item.)
Management Plan
[A numbered list of all action points, decisions, and plans stated by the clinician, including medications prescribed or changed, investigations requested, referrals made, follow-up arrangements, surgical plans, and advice given. If surgery is being offered or arranged, the first management point must document on separate lines: the name of the operation as stated by the clinician; whether it is under general or local anaesthetic as stated; whether it is a day case or overnight stay as stated; and the approximate duration as stated] (Always include this section. Never invent or infer a management plan. If no management actions were stated, else write: "No specific actions arranged at this consultation." Present each action point as a separate numbered item.)
During your visit, we discussed the following.
[The presenting complaint and history as provided by the patient, or by the accompanying adult if the patient is a child] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.)
Your Medical History
[Past medical history and previous surgeries as stated during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each item as a separate paragraph.)
Your Medications
[Current medications and any herbal supplements as stated during the consultation, including name, dose, and frequency where stated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each medication as a separate paragraph.)
Allergies
[Allergies as stated during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each allergy as a separate paragraph.)
Social History
[Smoking status, alcohol use, occupation, and home circumstances as discussed during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.)
On Examination
(Only include the sub-sections below that correspond to examinations explicitly performed and stated by the clinician. Omit any sub-section not explicitly mentioned in the transcript, contextual notes, or clinical note. Anterior rhinoscopy and flexible nasendoscopy are separate examinations and must not be combined or cross-labelled. If only one was performed, only that one appears. If both were performed, they appear under separate sub-headings with separate findings.)
Ears: [Otoscopy findings as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this sub-section entirely. Write as a full sentence on the same line.)
Tuning Fork Tests: [Rinne and Weber tuning fork test findings as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this sub-section entirely. Write as a full sentence on the same line.)
Oral Cavity And Throat: [Findings of the oral cavity and throat examination as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this sub-section entirely. Write as a full sentence on the same line.)
Neck: [Findings of the neck examination including lymph nodes, thyroid, and salivary glands as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this sub-section entirely. Write as a full sentence on the same line.)
Anterior Rhinoscopy: [Findings of the anterior nasal cavity as stated by the clinician. Do not include postnasal, pharyngeal, or laryngeal findings here.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this sub-section entirely. Write as a full sentence on the same line.)
Flexible Nasendoscopy: [Findings from the flexible nasendoscopy including the postnasal space, pharynx, and larynx as stated by the clinician. Do not include anterior nasal findings here.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this sub-section entirely. Write as a full sentence on the same line.)
[Any other examination explicitly performed and stated by the clinician, such as cranial nerve examination, facial nerve function assessment, or vestibular and balance testing, with findings as stated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence, as its own paragraph.)
Investigations And Results
[Tests performed during the appointment, tests arranged, and any results discussed, as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each investigation or result as a separate paragraph.)
Impression
[The clinician's explicitly stated impression or working diagnosis, and any plain-English explanation the clinician gave during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in full sentences, with each sentence as a separate paragraph.)
Discussion About Surgery
(Only include this entire section if surgery was explicitly discussed in the transcript, contextual notes, or clinical note. If surgery was not discussed, omit this section entirely.)
We discussed the option of [the name of the operation as stated by the clinician, with any plain-English description the clinician gave]. (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)
Anaesthetic: [Whether the procedure is under general or local anaesthetic, as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Admission: [Whether the procedure is a day case or requires an overnight stay, as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Approximate Duration: [The approximate duration of the procedure as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Alternatives Discussed: [Alternative treatments the clinician discussed, including the option of not proceeding with surgery if the clinician mentioned it] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write as a full sentence on the same line.)
The risks and complications we discussed were:
[Each risk or complication the clinician explicitly stated was discussed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Do not add risks that were not mentioned. Present each risk as a separate bullet point.)
[Any additional points the clinician discussed about recovery, time off work or school, or the consent process] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.)
What You Can Do To Help
[Self-care advice, techniques, or lifestyle measures given by the clinician, such as nasal douching, voice rest, avoiding cotton buds, positional manoeuvres, or smoking cessation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each piece of advice as a separate paragraph.)
When To Seek Urgent Help
[Red flags, warning symptoms, or urgent safety advice given by the clinician, together with the action the clinician advised] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each warning as a separate paragraph.)
Next Steps
[Follow-up plans, further investigations, or referrals stated by the clinician, if not already captured in the Management Plan above] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each next step as a separate paragraph.)
"Please do not hesitate to contact me if you have any questions or require further information."
"Please note this letter has been transcribed by Heidi Health, an AI transcribing tool, and has been checked for errors."
