wynonna
True Blue
HPI
patient is a 26 year old exposed while in the military for 6 years referred today for evaluation of intermittent, bilateral tinnitus. Medical records from his PCP's office were personally reviewed by me. He reports tinnitus (right worse than left) and hearing concerns for approximately 3 years which have progressively worsened
AND Assessment and Plan
(1) Tinnitus, bilateral:
(2) Abnormal auditory perception of both ears:
Plan
Masking strategies discussed and recommend patient continue hearing protection. Will monitor asymmetry with repeat audiogram in 3 months
EXAM is detailed/comprehensive
( masking is asking pt to listen to white noise or soothing music to mitigate ringing in ears)
Would you score as level 2 or 3?
patient is a 26 year old exposed while in the military for 6 years referred today for evaluation of intermittent, bilateral tinnitus. Medical records from his PCP's office were personally reviewed by me. He reports tinnitus (right worse than left) and hearing concerns for approximately 3 years which have progressively worsened
AND Assessment and Plan
(1) Tinnitus, bilateral:
(2) Abnormal auditory perception of both ears:
Plan
Masking strategies discussed and recommend patient continue hearing protection. Will monitor asymmetry with repeat audiogram in 3 months
EXAM is detailed/comprehensive
( masking is asking pt to listen to white noise or soothing music to mitigate ringing in ears)
Would you score as level 2 or 3?