ENT REPORT

Patient: Mrs. Evelyn Carter 1 November 2024 History Complaints – Mrs. Carter presents with a three-week history of right ear pain, accompanied by a feeling of fullness and reduced hearing. She reports no fever, but does note occasional mild dizziness. The symptoms are worse at night. Medication – Mrs. Carter is currently taking Lisinopril 10mg daily for hypertension and a daily multivitamin. Illnesses – Mrs. Carter has a history of hypertension, well-controlled with medication. She denies any previous ear problems or surgeries. **Examination** "Ears Right:" Right tympanic membrane is erythematous and slightly bulging. There is a small amount of clear fluid visible behind the tympanic membrane. No perforation is noted. "Left:" Left tympanic membrane appears normal, with good light reflex. No fluid or inflammation is observed. Audiogram – Audiometry reveals mild conductive hearing loss in the right ear, consistent with fluid in the middle ear. Diagnosis – Acute otitis media, right ear. Plan – Prescribe Amoxicillin 500mg three times daily for 7 days. Advise Mrs. Carter to return for a follow-up appointment in two weeks to assess resolution of symptoms and hearing. Provide patient education on the importance of completing the full course of antibiotics. Thank you. Kind regards