Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Describe the voice problem:
Onset (sudden or gradual)
Duration
Voice quality (hoarseness, breathiness, weakness, strain)
Pitch (higher or lower than usual)
Volume (difficulty being heard)
Any associated pain or discomfort
Impact on daily activities (work, social interactions)
Inquire about vocal hygiene habits:
Vocal strain (yelling, excessive talking)
Smoking history
Alcohol consumption
Ask about medical history:
Previous respiratory illnesses (colds, allergies)
Neurological conditions
Gastroesophageal reflux disease (GERD)
Medications (some medications can cause dry mouth or voice changes)
Objective:
General: Assess overall health and well-being.
ENT Exam:
Larynx palpation (feel for nodules, polyps, or masses on the voice box).
Mirror examination of the vocal cords (indirect laryngoscopy) – if possible – to visualize vocal fold vibration and function.
Other exams (if indicated):
Nasopharyngoscopy (exam of the back of the nose and throat)
Flexible laryngoscopy (visualization of the vocal cords with a thin, flexible scope)
Stroboscopy (visualization of vocal fold vibration using specialized lighting)
Assessment:
Dysphonia (voice disorder) – specify the type of voice change (e.g., hoarse, breathy)
Consider potential causes based on history, exam findings, and any additional tests:
Vocal fold nodules or polyps (benign growths)
Muscle tension dysphonia (vocal misuse)
Vocal fold paresis/paralysis (weakness or immobility of vocal folds) due to neurological conditions
Reflux laryngitis (irritation from stomach acid)
Presbyphonia (age-related voice changes)
Other less common causes (e.g., vocal fold cancer)
Plan:
Treatment will depend on the underlying cause of dysphonia.
Discuss treatment options with the patient:
Voice Therapy: Most common treatment for muscle tension dysphonia and improper vocal habits. A speech-language pathologist can teach vocal hygiene techniques and exercises to improve voice quality.
Medications: For reflux laryngitis, consider medications to reduce stomach acid.
Surgery: In some cases, surgery may be necessary to remove vocal fold lesions or address underlying anatomical problems.
Observation: For mild cases without a clear cause, watchful waiting may be appropriate.
General Recommendations:
Maintain good vocal hygiene: avoid yelling, whispering, or excessive talking.
Stay hydrated: drink plenty of fluids to keep vocal cords lubricated.
Limit irritants: avoid smoking and excessive alcohol consumption.
Address allergies or respiratory issues if contributing to voice problems.
Follow-up:
Schedule follow-up visits to monitor response to treatment and adjust the plan as needed.
Consider referral to an otolaryngologist (ENT specialist) for complex cases or if surgery is being considered.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding voice characteristics, associated symptoms, risk factors, physical exam findings, and treatment plan.