Date:
Patient:
Reason for Visit: Sudden sensorineural hearing loss (SSNHL)
History of Present Illness:
Date of hearing loss onset (ideally pinpoint the exact day)
Laterality (unilateral or bilateral)
Severity and description of hearing loss (sudden deafness, muffled hearing, tinnitus, fullness in ear)
Associated symptoms (vertigo, imbalance, ear pain, fever, upper respiratory infection symptoms)
Prior history of ear infections, head trauma, or noise exposure
Ototoxic medication use (if any)
Past Medical History:
Relevant medical conditions (diabetes, hypertension, autoimmune diseases)
Previous surgeries (ear surgeries, head and neck surgeries)
Family History:
Hearing loss in family members
Social History:
Occupational noise exposure
Smoking history
Physical Exam:
Vital signs (temperature, blood pressure)
Ear canal examination (wax buildup, inflammation, signs of infection)
Otoscopy (eardrum integrity, mobility)
Neurological exam (assessing for cranial nerve deficits, balance)
Head and neck exam (looking for signs of infection or masses)
Diagnostic Studies:
Audiometry (pure tone and speech audiometry) to assess hearing thresholds and type of hearing loss
Tympanometry (measures middle ear function)
Consideration of:
Auditory brainstem response (ABR) to assess neural pathway involvement
Imaging studies (MRI) to rule out structural abnormalities or tumors (if indicated)
Diagnosis:
Sudden sensorineural hearing loss (unilateral or bilateral)
Mention laterality and severity (e.g., profound hearing loss)
If a specific cause is identified, mention it (e.g., SSNHL secondary to viral infection)
Management:
Summarize the treatment plan:
Oral steroids (prednisone) are the mainstay of treatment to reduce inflammation.
Mention alternative options if steroids are contraindicated (antiviral medications, hyperbaric oxygen therapy – if available)
Explain the importance of starting treatment promptly (ideally within 48 hours)
Plan:
Outline the plan for the next day(s):
Schedule for repeat audiometry to monitor hearing recovery
Consideration for additional testing results (ABR, MRI)
Follow-up appointments to monitor response to treatment and adjust medication as needed
Referral to an audiologist for potential hearing aid fitting (if significant hearing loss persists)
Prognosis:
Briefly discuss the prognosis based on:
Time from symptom onset to treatment initiation
Severity of hearing loss
Underlying cause (if identified)
Mention the potential for spontaneous recovery or partial recovery, even with treatment.
Additional Information:
Document any limitations or difficulties with communication due to hearing loss.
Note patient education provided regarding the condition and treatment plan.