Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Vertigo (episodes of spinning sensation) lasting 20 minutes to several hours
Tinnitus (ringing or buzzing in the ear)
Hearing loss (fluctuating or constant) in the affected ear (unilateral)
Feeling of ear fullness or pressure (aural fullness)
History of Present Illness:
Inquire about the following for each symptom (vertigo, tinnitus, hearing loss, aural fullness):
Onset, duration, frequency, and severity
Any aggravating or alleviating factors (e.g., head position, stress, certain foods)
Associated symptoms (e.g., nausea, vomiting, sweating)
Describe the characteristics of the vertigo episodes (rotatory, tilting, etc.).
Ask about the laterality of symptoms (which ear is affected).
Past Medical History:
Inner ear infections or injuries
Migraine headaches
Allergies
Head trauma
History of noise exposure
Medications:
List all current medications, including any medications used for vertigo or tinnitus.
Social History:
Inquire about tobacco use (may worsen symptoms).
Caffeine intake (may worsen symptoms for some).
Exposure to loud noises (occupational or recreational).
Family History:
Family history of Ménière’s disease or other inner ear disorders.
Physical Exam:
General examination: Assess vital signs for normal range.
Neurologic examination:
Evaluate for spontaneous nystagmus (involuntary eye movements) during a vertigo episode.
Assess for gait and coordination abnormalities suggestive of central nervous system involvement (unlikely in Ménière’s disease).
Ear examination:
Otoscopy to assess for abnormalities of the eardrum and external ear canal.
Consider tympanometry (measures middle ear pressure function).
Weber test and Rinne test (lateralization tests for hearing loss).
Diagnostic Testing (not all may be necessary in every case):
Audiometry: Evaluates hearing thresholds across different frequencies.
Vestibular function testing (VNG or video head impulse test – vHIT): Assesses balance function and may reveal canalithiasis (debris in inner ear canals) which can mimic Ménière’s symptoms.
Magnetic Resonance Imaging (MRI) of the brain: May be indicated to rule out other central nervous system causes of vertigo (especially if neurological exam findings are abnormal).
Assessment:
Ménière’s disease (possible/probable/definite): Base diagnosis on clinical presentation (characteristic symptoms) and consider the results of diagnostic tests to increase diagnostic certainty.
Possible: Meets some but not all criteria for Ménière’s disease.
Probable: Meets most criteria with some limitations.
Definite: Meets all diagnostic criteria.
Plan:
Treatment (depends on disease severity and frequency of attacks):
Lifestyle modifications:
Dietary changes (avoiding salt, caffeine, and alcohol for some patients)
Stress management techniques
Balance exercises (vestibular rehabilitation)
Medications:
Diuretics to reduce inner ear fluid volume (e.g., hydrochlorothiazide)
Antiemetics for nausea and vomiting during vertigo attacks
Antihistamines (may reduce vertigo frequency for some)
Intratympanic injections: Injections of medications (steroids or gentamicin) into the middle ear in specific cases.
Surgical intervention (considered for severe cases with frequent debilitating attacks unresponsive to other measures):
Endolymphatic sac decompression procedures
Vestibular nerve section (surgical destruction of the balance function in the affected ear)
Hearing management: If hearing loss is significant, consider referral for hearing aids or other assistive listening devices.
Follow-up: Schedule regular follow-up visits to monitor symptoms, response to treatment, and hearing function.
Education:
Educate the patient about Ménière’s disease, symptoms, risk factors, and treatment options.
Discuss the importance of lifestyle modifications and adherence to medication regimens.
Provide resources for Ménière’s disease support groups or patient advocacy organizations.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Ménière’s disease