Audiology Consultation Note

Valmis merkintä

Patient Identification: adult patient presenting with gradually reduced hearing in both ears.

History of Present Illness:
Reports difficulty following conversation in groups for about one year, especially when background noise is present. Family has noticed the patient asks for repetition more often. No sudden change, ear pain, drainage, or spinning sensation. No previous hearing aids or formal audiology testing.

Review of systems specific to the speciality: No tinnitus or imbalance reported.

Impact on daily life: Group conversations at work are increasingly difficult; one-to-one discussion remains manageable.

Past Medical History:
- No relevant otologic history reported.

Medications:
- No regular medications reported.

Allergies:
- No known allergies reported.

Family History:
- No known family hearing loss reported.

Social History:
- Reports occasional recreational noise exposure; uses hearing protection inconsistently.

Physical Examination:
- HR: 72 bpm, BP: 122/76 mmHg, T: 36.7 °C, RR: 14/min, SpO₂: 99%.
- Ear examination: Canals clear; tympanic membranes intact bilaterally.
- Cranial nerves: Grossly symmetric facial movement.

Audiologic Assessment:
- Pure tone audiometry: Mild-to-moderate bilateral high-frequency sensorineural loss.
- Speech recognition: Word recognition good in quiet bilaterally.
- Tympanometry: Type A bilaterally.

Investigations:
- No imaging indicated from today’s findings.

Assessment & Plan:
Adult patient with bilateral high-frequency sensorineural hearing loss.

1) Hearing difficulty
- Reviewed results and communication strategies; discussed hearing aid evaluation.
- Recommend consistent hearing protection and repeat audiogram in one year, sooner for sudden change.

Havainnollistava tapaus, jossa potilastiedot ovat keksittyjä. Tämä ei ole oikea potilasasiakirja eikä kliinistä ohjeistusta. Tarkista jokainen merkintä oman vastaanottosi perusteella.

Merkinnän taustalla olevat kliiniset faktat

Uudelleen käytettävä pohjarakenne

Audiologist Consult Note

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

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

[Impact on daily life, communication difficulties, occupational or social effects]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions, especially otologic, neurologic, or systemic diseases]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug, food, or environmental allergies]

Family History:
(hyphenated list)
- [Hearing loss, otologic disorders, genetic conditions]

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 to noise or ototoxic agents]
- [Living situation: who lives with patient, home environment]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Ear examination: external ear, canal, tympanic membrane findings]
- [Cranial nerve assessment if relevant]
- [Other relevant systems]

Audiologic Assessment:
(hyphenated list)
- [Pure tone audiometry: degree, type, and configuration of hearing loss]
- [Speech audiometry: speech recognition thresholds, word recognition scores]
- [Immittance testing: tympanometry, acoustic reflexes]
- [Otoacoustic emissions]
- [Other specialized tests: ABR, ECochG, vestibular testing]

Investigations:
(hyphenated list)
- [Relevant laboratory or imaging results]

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

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line)
- [Further audiologic or medical investigations planned or ordered]
- [Treatment plan: hearing aids, assistive devices, medical or surgical referral]
- [Counselling discussion: communication strategies, prognosis, education]
- [Referrals sent: ENT, neurology, speech-language pathology, etc.]
- [Follow up plan]
- [Return precautions]