ENT/Otolaryngology Consult

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

ENT/Otolaryngology Consult Note

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Structure symptoms and associated information into distinct paragraphs. Use full sentences and formal clinical language. Include onset, duration, progression, associated symptoms, prior interventions, and relevant exposures.)

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]

Past Surgical History:
(hyphenated list)
- [Surgical procedures and dates]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Amoxicillin 500 mg oral TID)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Father: hearing loss)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

Review of Systems:
(hyphenated list)
- [ENT: hearing loss, tinnitus, vertigo, nasal congestion, epistaxis, sore throat, dysphagia, hoarseness, otalgia, otorrhea, etc.]
- [Other relevant systems as indicated]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- General: [Appearance, distress]
- Head: [Inspection, tenderness, deformity]
- Ears: [External ear, canal, tympanic membrane, hearing tests]
- Nose: [External nose, septum, turbinates, mucosa]
- Throat: [Oropharynx, tonsils, mucosa, lesions]
- Neck: [Lymphadenopathy, masses, thyroid]
- Cranial Nerves: [Findings if assessed]
- [Other relevant systems as indicated]

Investigations:
(hyphenated list)
- [Investigation results with units] (e.g., Audiogram, imaging, labs)

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary ENT diagnosis or concern]

#) [Assessment as a numbered item if multiple issues]
- (Hyphenated list with each corresponding plan item on a new line) - [Further investigations]
- [Treatment]
- [Referrals]
- [Follow-up] 
- [Patient education]