wynonna
True Blue
Assessment and Plan
(1) Cerumen impaction:
Qualifiers:
Laterality: bilateral Qualified Code(s): H61.23 - Impacted cerumen, bilateral
Plan:
both ear cleaned microscopically with suction and curette.
(2) Pressure sensation in left ear:
Plan:
it is hard to tell if pt has effusion behind the left ear or the conductive hearing loss is secondary to cerumen layering on the eardrum, we will have pt follow up 6 weeks with another audiogram.
Intake
Visit Reasons: 4 months wax w/ audio
Chief complaint:
Patient presents today for ear care and audiogram.
Other results
Audiogram today reviewed personally:
right ear:250-3000 Hz WNL, 4000-8000Hz moderate SNHL.
left ear:250 Hz mild loss, 500Hz WNL, 1000-8000Hz mild to severe mixed loss. air bone gaps of 10dB at 1000Hz and 30dB at 4000Hz.
normal Type A tympanograms for right ear, Ad for the left, excellent word clarity.
(1) Cerumen impaction:
Qualifiers:
Laterality: bilateral Qualified Code(s): H61.23 - Impacted cerumen, bilateral
Plan:
both ear cleaned microscopically with suction and curette.
(2) Pressure sensation in left ear:
Plan:
it is hard to tell if pt has effusion behind the left ear or the conductive hearing loss is secondary to cerumen layering on the eardrum, we will have pt follow up 6 weeks with another audiogram.
Intake
Visit Reasons: 4 months wax w/ audio
Chief complaint:
Patient presents today for ear care and audiogram.
Other results
Audiogram today reviewed personally:
right ear:250-3000 Hz WNL, 4000-8000Hz moderate SNHL.
left ear:250 Hz mild loss, 500Hz WNL, 1000-8000Hz mild to severe mixed loss. air bone gaps of 10dB at 1000Hz and 30dB at 4000Hz.
normal Type A tympanograms for right ear, Ad for the left, excellent word clarity.