ENT Consult Letter Template BWU

Chief Complaint

ENT Consult Letter Template

Template

Dear Dr. [referring_physician_last_name], Thank you for referring this [patient_age]-year-old [male/female/boy/girl] regarding [chief_complaint/reason_for_consultation]. HISTORY OF PRESENT ILLNESS: [patient_name] presents with [chief_complaint]. [pronoun] [ear_nose_throat_symptoms] have [been_stable/improved/recurred/not_improved] since [last_visit/onset]. [Document the details surrounding the patient's chief complaint. Include onset, duration, frequency, severity, and any associated symptoms. Describe the parent’s account of the current issues they are having in relation to the chief complaint and any concerns or expectations they express.] MEDICATIONS: [medications_list with relevant medical conditions] ALLERGIES: [medication_allergies_and_reactions, only include if discussed, if none reported write NKDA] SOCIAL HISTORY: [list smoking status, pack years etc] [document alcohol consumption] [list occupation, noise exposure, vocal demand] PHYSICAL EXAMINATION: [Detail findings of the physical examination] [If Normal Exam is mentioned, write the following paragraph: Bilateral otoscopy showed intact canals and tympanic membranes. No effusion or retraction seen. Anterior rhinoscopy and nasal endoscopy showed clear nasal passages and nasopharynx. Pharynx and larynx were normal. Oral cavity and oropharynx were clear. Neck palpation did not reveal any mass or cervical adenopathy. (scope #)] [If appointment was conducted by telehealth, indicate: Physical examination was limited by telehealth modality, and only describe results of visual examination explicitly noted in the transcript.] Vitals: BP [bp], HR [hr], RR [rr], Temp [temp], O2 Sat [o2_sat]%, [Weight, Height, calculated BMI], Neck circumference INVESTIGATIONS: Audiometry: [date_performed] - Hearing: [hearing_findings, Right (AD), Left (AS)] - Hearing range: [hearing_range] - Tympanometry: Right: type [type], Left: type [type] - OAE: [oae_findings] - SRT: Right: [srt_right]; MCL= Left: [srt_left]; MCL= - WDS: Right: PB% @ [wds_right] Left: PB% @ [wds_left] Imaging: [relevant_findings] Otolaryngic allergy testing: [relevant_findings] - Skin prick allergen testing was conducted with appropriate positive and negative controls. - The patient reacted [negatively or positively] to all allergens tested, including dust mites, grasses, trees, weeds, and molds. PROCEDURE: [If Cauterization of septum is mentioned, write: Topicalized, cauterization of [right/left] septum, Gelfoam/Surgicel packing and Polyderm applied.] [If myringotomy and drainage of the ear is mentioned, write: Topicalized, phenol applied, anterior/inferior incision over [right/left] TM, [serous/mucoid] discharge evacuated, [tube/no tube] inserted, Ciprodex drops applied.] [If fine-needle aspiration is mentioned, write: FNA Biopsy performed (specific area of the body), sent for cytologic evaluation.] ASSESSMENT/PLAN: [diagnosis/diagnoses] 1. [management_plan] 2. [medication_changes] - [drug_name] Drops [frequency] to [ear] 3. [procedures_performed_today] - [procedure] 4. [surgery_recommendations] - [surgery_details] 5. [follow_up_instructions] - Review in [time_frame] - Review at [hospital] for [reason] 6. [patient_education_provided] - [education_details] 7. [referrals] - Referred to [specialist/service] for [reason] Thank you for involving me in the care of your patients.