My Clinic
5225 Pilsbury Lane
Audiologic Report Hometown, WI 55214
Phone: (608)878-6596
Fax: (608)878-6597
Patient Name: Joe Smith Audiologist: John Smith, Au.D.
Date of Birth: 04/05/1945 Title: Audiologist
Visit Date: 03/15/2016 Referring Provider: Joanne Topkins, M.D.
CONFIGURATION QuickSIN [EP]
Audiometer GSI-61 SNR Degree (Loss)
Calibration 07/03/2009 Mild (3-7 dB)
Reliability Good
Test Method Conventional
Transducer Inserts
TYMPANOMETRY [226 Hz] DPOAE Screen
Right Left Right Left
Type A A Pass Pass
Pressure (daPa) -55 -44
Admittance (cc) 1.22 1.44 PTA (3 Freqs)
ECV (cc) 1.24 1.14 Right Left
Gradient (daPa) 88 78 35 33.33
Neg: No significant reflex decay Pos: Significant reflex decay Abs: Absent Pres: Present WNL: Within Normal Limits Red: Reduced
NR: No Response CNS: Could Not Seal CNT/DNT: Could/Did Not Test WR: Word Recognition SF:Soundfield EP: Earphones
WORD RECOGNITION (Presentation: MLV / Word List: NU-6) SPEECH AUDIOMETRY (Word List: Spondees)
dBHL % Mask dBHL % Mask SAT SRT Mask MCL UCL
Right 65 88 40 70 96 45 Right 20 20 65 105
Left 65 84 40 70 92 45 Left 25 25 65 110
HISTORY: Primary concern: Possible decrease in hearing sensitivity, bilaterally. Aural fullness/pressure (Bilateral):
Constant. Denied any tinnitus, otalgia, fluctuations in hearing, vertigo, noise exposure, ear surgery, or family Hx of hearing loss.
All other medical history was unremarkable. Medications: Coumadin.
RESULTS: Otoscopy: Clear ear canals, bilaterally. Tympanometry: Normal TM mobility, middle ear pressure, and ear canal
volume, bilaterally. Pure tone testing (Symmetric): Right Ear - Mild-Severe Sensorineural Sloping Hearing Loss; Left Ear -
Mild-Severe Sensorineural Sloping Hearing Loss. Word Recognition: Excellent bilaterally. QuickSIN: Mild Signal-to-Noise
Ratio (SNR) loss indicating difficulty with speech understanding in the presence of background noise.
RECOMMENDATIONS:
1. Follow-up with Joanne Topkins, M.D. to review today's results.
2. Consider a trial with amplification.
3. Wear hearing protection whenever in noisy situations.
xx x x
Audiologist: Date: 03/15/2016
x John Smith, Au.D. xx x xx
License #: 223-344A
CC: Joanne Topkins, M.D., Peter Simpson, CPNP/APN, Michael Abers, M.D.
Joe Smith [DOB 04/05/1945] - 03/15/2016 - Page 1 of 1