Audio

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

Narrative: An examination of hearing impairment must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (specifically, the Maryland CNC recording) and a pure tone audiometry test in a sound isolated booth that meets American National Standards Institute standards (ANSI S3.1. 1991) for ambient noise. Measurements will be reported at the frequencies of 500, 1000, 2000, 3000, and 4000 Hz. The examination will include the following tests: Pure tone audiometry by air conduction at 250, 500, 1000, 2000, 3000, 4000, and 8000 Hz, and by bone conduction at 250, 500, 1000, 2000, 3000, and 4000 Hz, spondee thresholds, speech recognition using the recorded Maryland CNC Test, tympanometry and acoustic reflex tests, and, when necessary, Stenger tests. Bone conduction thresholds are measured when the air conduction thresholds are poorer than 15 dB HL. A modified Hughson-Westlake procedure will be used with appropriate masking. A Stenger must be administered whenever pure tone air conduction thresholds at 500, 1000, 2000, 3000, and 4000 Hz differ by 20 dB or more between the two ears. Maximum speech recognition will be reported with the 50 word VA approved recording of the Maryland CNC test. When speech recognition is 92% or less, a performance intensity function will be obtained with a starting presentation level 40 dB re SRT. If necessary, the starting level will be adjusted upward to obtain a level at least 5 dB above the threshold at 2000 Hz. The examination will be conducted without the use of hearing aids. Both ears must be examined for hearing impairment even if hearing loss in only one ear is at issue.

A. Review of Medical Records: Indicate whether the C-file was reviewed.

B. Medical History (Subjective Complaints):

Comment on:

1. Chief complaint.
2. Situation of greatest difficulty.
3. Pertinent service history.
4. History of military, occupational, and recreational noise exposure.
5. Pertinent family and social history; history of ear disease, head or ear trauma etc.
6. Tinnitus - Is there a current complaint of tinnitus? (yes/no) If yes, indicate the following:

1. Date and circumstances of onset.
2. Whether it is unilateral or bilateral.
3. Whether it is constant or recurrent.
4. If recurrent (intermittent), indicate the frequency and duration of tinnitus episodes.

INSTRUCTIONS:

1. Refer to 2507 for claimed disabilities.
2. If veteran has filed a claim for tinnitus and there is a current complaint of tinnitus, answer the questions above.
3. If tinnitus is claimed and the veteran denies complaints of tinnitus, answer no to the above question and do not answer subsequent questions.
4. If tinnitus is not claimed but the veteran reports a complaint of tinnitus, then note the presence of tinnitus in Section B (History).

C. Physical Examination (Objective Findings):

1. Measure puretone thresholds in decibels at the indicated frequencies (air conduction):

RIGHT EAR	LEFT EAR
A* B C D E **	A* B C D E **
500 | 1000 | 2000 | 3000 | 4000 | average	500 | 1000 | 2000 | 3000 | 4000 | average

* The puretone threshold at 500 Hz is not used in determining the evaluation but is used in determining whether or not a ratable hearing loss exists. Puretone thresholds should not exceed 105 decibels or the tolerance level.
** The average of B, C, D, and E.

2. Speech Recognition Score: Maryland CNC word list

_______% right ear ______% left ear.

When only puretone results should be used to evaluate hearing loss, the examiner, who must be a state-licensed audiologist, should certify that language difficulties or other problems (specify what the problems are) make the combined use of puretone average and speech discrimination inappropriate.

Thresholds should not exceed 100 decibels or the tolerance level.

D. Diagnostic and Clinical Tests:

1. Report middle ear status, confirm type of loss, and indicate need for medical follow-up. In cases where there is poor inter-test reliability and/or positive Stenger test results, obtain and report estimates of hearing thresholds using a combination of behavioral testing, Stenger interference levels, and electrophysiological tests.
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Summary of audiologic test results. Indicate type and degree of hearing loss for the frequency range from 500 to 4000 Hz. For type of loss, indicate whether it is normal, conductive, sensorineural, central, or mixed. For degree, indicate whether it is mild (26-40 HL), moderate (41-54 HL), moderately severe (55-69HL), severe (70-89 HL), or profound (90+HL).
   
   [For VA purposes, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hz is 40 dB HL or greater; or when the auditory thresholds for at least three of these frequencies are 26 dB HL or greater; or when speech recognition scores are less than 94%.]
   
   
2. Note whether, based on audiologic results, medical follow-up is needed for an ear or hearing problem, and whether there is a problem that, if treated, might cause a change in hearing threshold levels.
   
   
3. If there is a current complaint of tinnitus, indicate whether or not tinnitus is as likely as not a symptom associated with the hearing loss, if hearing loss is present. If tinnitus is associated with conditions other than hearing loss indicate that the complaint of tinnitus requires referral to another provider (appropriate provider to be determined by VAMC C&P Director or other responsible person as with contractors) for determination of etiology.

Signature:

Date: