Otolaryngology Consultation Note (Inpatient/ED)

Date/Time of Evaluation: [Date and time of patient evaluation]

Date/Time of Note: [Date and time of documentation]

Location: [ED / floor unit / ICU]

Requesting Service: [Service name]

Requesting Clinician: [Name and role] (Include if known)

Consult Priority: [routine / urgent / emergent]

Reason for Consult

[Specific consult question or clinical concern prompting ENT evaluation] (Include the clinical trigger if relevant. If the question was unclear, document how it was clarified or note that a focused ENT evaluation was performed to address airway, bleeding, and infection concerns.)

ENT Recommendations

Airway status: [stable / at risk / unstable] — [brief summary of airway patency and current support]

• [Actionable recommendation with medication dose/route/frequency when ENT is directing therapy]
• [Additional actionable recommendations as needed]
• [NPO status and rationale] (Include if applicable)
• [Monitoring parameters and frequency]
• [Urgent consults or co-management requested] (Include if applicable)
• Contingency: If [escalation trigger with objective criteria], then [specific action and who to contact]

Disposition: [Location, level of care, and timing for ENT re-evaluation]

History of Present Illness

[Focused narrative tailored to the consult question including onset, duration, progression, relevant context, prior treatments, and impact on function] (Note the historian and reliability. Include pertinent negatives relevant to risk stratification.)

• Historian: [self / family / staff / chart review] | Reliability: [reliable / limited] (If limited, state why)
• Airway safety screen: [Presence/absence of stridor, voice change, dyspnea, dysphagia, drooling, positional breathing difficulty, secretion intolerance, prior difficult airway]
• Bleeding safety screen: [Active bleeding status, estimated volume, laterality, posterior symptoms, prior interventions, hemodynamic symptoms, anticoagulant/antiplatelet use with last dose] (Include when relevant)
• Infection safety screen: [Fever, neck swelling, trismus with interincisal distance, odynophagia, dental source, immunocompromised state, rapid progression] (Include when relevant)
• Relevant prior ENT history: [Tracheostomy, head/neck radiation, prior head/neck cancer, prior surgeries, prior epistaxis treatments, prior intubations] (Include pertinent items)
• History limitations: [Reason if unobtainable or limited] (Omit if history fully obtained)

Pertinent Medical History and Medications

• Comorbidities impacting ENT risk: [OSA, coagulopathy, liver disease, CKD, diabetes, immunosuppression, other relevant conditions]
• Anticoagulants/antiplatelets: [Agent(s) with last dose and time; reversal agents given if any]
• Recent antibiotics or steroids: [Agent, dose, start date] (Include if relevant)
• Allergies: [Drug/agent and reaction type]
• Home airway devices: [CPAP/BiPAP settings, supplemental oxygen] (Include if relevant)

Objective

Vitals: T [value], HR [value], BP [value], RR [value], SpO2 [value]% on [room air / supplemental O2 with delivery method and rate], mental status [alert and oriented / altered] (Note hemodynamic instability explicitly if present)

General/respiratory: [Appearance, distress level, work of breathing, ability to speak, secretion management]

Airway/voice: [Voice quality, stridor characteristics, stertor, drooling, airway adjuncts in place]

Oral cavity/oropharynx: [Mucosa, tongue, tonsils, uvula position, pooling secretions, trismus with interincisal distance, dentition, floor of mouth]

Nose: [Anterior rhinoscopy findings, bleeding site if visualized, clots/crusting, septal abnormalities, existing packing]

Neck: [Tenderness, swelling, fluctuance, induration, erythema, crepitus, tracheal position, range of motion, lymphadenopathy]

Ears/Cranial nerves: [Findings] (Include only when relevant to the consult)

Exam limitations: [Limitations and reasons] (Omit if exam complete)

Flexible nasolaryngoscopy/nasal endoscopy: (Include only if performed)

• Indication: [Reason for procedure]
• Topical agents: [Agents used]
• Route: [right naris / left naris / oral]
• Adequacy: [adequate / limited due to (reason)]
• Findings: Nasal cavity: [findings]; Nasopharynx: [findings]; Oropharynx: [findings]; Hypopharynx: [findings including secretion pooling]; Larynx: [edema, lesions, bleeding source, vocal fold mobility R/L]
• Patient tolerance: [well tolerated / limited by gag, desaturation, or agitation]

Key labs reviewed: [CBC, coagulation studies, BMP, lactate, other relevant values with date/time] (Note pending labs affecting management)

Imaging: [Study name, date/time, interpretation source, and salient findings relevant to consult] (Do not reproduce full radiology reports)

Assessment

[Clinical synthesis: patient summary, key pathology, and risk level] (Include severity/trajectory statement: airway [stable / at risk / unstable]; bleeding [controlled / ongoing, anterior / posterior]; infection [localized / deep space, sepsis concern]. Include brief differential only when it affects management.)

Plan

(Organize by problem in descending acuity. Be specific and actionable. Clarify ENT responsibilities versus primary team responsibilities.)

[Problem 1: Primary ENT concern]

• Diagnostics: [Tests, imaging, or scope with responsible team]
• Therapeutics: [Medications with dose/route/frequency; topical agents; other treatments]
• Procedures/OR plan: [Bedside vs OR, timing, consent status, anesthesia plan] (Include if applicable)
• Monitoring: [Parameters, frequency, escalation triggers, and who to contact]
• Airway escalation plan: [Criteria for ENT STAT, anesthesiology involvement, equipment at bedside, surgical airway contingency] (Include for airway concerns)
• Anticoagulation management: [Hold/continue decision, reversal plan, responsible service] (Include for bleeding concerns)
• NPO status: [NPO / diet level with duration and criteria to advance] (Include if applicable)
• Disposition: [Discharge vs admission, level of care, timing for ENT re-evaluation]
• Responsibilities: ENT: [actions] | Primary team: [actions]

[Problem 2: Secondary issue]

• Diagnostics: [Details]
• Therapeutics: [Details]
• Monitoring/contingencies: [Details]
• Follow-up: [Details]

(Add additional problems as needed)

Procedure Note

(Include only if a bedside procedure was performed)

• Procedure: [Name with laterality/site]
• Date/Time: [Date and time performed]
• Indication: [Reason for procedure]
• Consent: [written / verbal / emergent without consent due to (reason)]
• Time-out: Performed per facility protocol
• Anesthesia: [Agents and route]
• Technique: [Key steps and materials used]
• Findings: [Procedural findings]
• Specimens: [Specimen type and destination] (Include if applicable)
• EBL: [Estimated blood loss] (Include if applicable)
• Complications: [none / description]
• Post-procedure status: [Hemostasis, airway stability, patient tolerance]
• Aftercare: [Instructions, packing precautions, follow-up timing, return precautions]
• Instructions to nursing/primary team: [Diet, humidification, suctioning, monitoring parameters, packing removal timing and responsible service]

Communication and Follow-up

• Communication with primary team: [Who, method, and key content discussed]
• Patient/family education: [Risks discussed, plan reviewed, warning signs to watch for]
• ENT follow-up: [Timing of re-evaluation; criteria for ENT sign-off]
• Outpatient follow-up: [Clinic referral, pending studies, timeframe] (Include if applicable)

Author: [Name and credentials]

(Omit sections not relevant to this encounter. Document explicitly when critical information is missing or unobtainable and state the reason. Do not infer findings, results, or interventions not directly verified.)