Diagnostic Radiologist Template

1st ENT Consult

A professional Diagnostic Radiologist template for healthcare professionals.

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Specialty

Diagnostic Radiologist

Used

14 times

Type

Document

Last edited

5/21/2025

Created by

Colin Turner

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About this template

The 1st ENT Consult template is designed for clinicians, particularly those in otolaryngology, to document initial consultations for ear, nose, and throat issues. This comprehensive template captures patient demographics, presenting complaints, detailed history, ENT-specific symptoms, and examination findings. It also includes sections for past medical and surgical history, medications, social and family history, and a management plan. Ideal for ENT specialists, this template ensures thorough documentation of initial patient assessments, facilitating accurate diagnosis and treatment planning. When used with Heidi, it streamlines the documentation process, enhancing clinical efficiency.

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Date: 01/11/2024 PATIENT DEMOGRAPHICS Name: John Doe DOB: 15/05/1980 Age: 44 Gender: Male Referred by: Dr. Sarah Smith PRESENTING COMPLAINT Persistent ear pain and hearing loss in the right ear. HISTORY OF PRESENTING COMPLAINT Duration: 3 weeks Site: Right ear Onset: Gradual Character: Dull, aching pain Radiation: None Associated symptoms: Occasional tinnitus Aggravating factors: Loud noises Relieving factors: Rest ENT SPECIFIC SYMPTOMS Ear: - Pain: Persistent dull ache in the right ear - Discharge: None - Hearing loss: Notable in the right ear - Tinnitus: Occasional ringing in the right ear - Vertigo: None Nose: - Obstruction: None - Discharge: None - Epistaxis: None - Smell disturbance: None - Facial pain/pressure: None Throat: - Sore throat: None - Dysphagia: None - Voice changes: None - Snoring/sleep apnoea: None PAST MEDICAL HISTORY Hypertension PAST SURGICAL HISTORY Appendectomy in 2005 MEDICATIONS Current: Lisinopril 10mg daily Allergies: Penicillin SOCIAL HISTORY Smoking: Non-smoker Alcohol: Occasional Occupation: Accountant FAMILY HISTORY Father with a history of hearing loss EXAMINATION General appearance: Well-nourished, alert Ear examination: Right: Redness and swelling observed, reduced hearing Left: Normal Nose examination: External: Normal Anterior rhinoscopy: Normal Posterior rhinoscopy: Normal Oral cavity and oropharynx: Dentition: Good Tongue: Normal Tonsils: Normal Posterior pharyngeal wall: Normal Neck examination: Lymph nodes: No enlargement Thyroid: Normal INVESTIGATIONS Audiogram showing mild conductive hearing loss in the right ear IMPRESSION Right ear otitis media with effusion PLAN - Prescribe amoxicillin 500mg TID for 7 days - Follow-up in 2 weeks - Consider ENT referral if no improvement Dr. John Doe ENT Consultant ICD 10 codes: H66.9