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
"Patient:" (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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[Date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.)
**History**
Complaints –
[Description of the patient's presenting complaints, symptoms, and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.)
Medication –
[List of current medications including dosage and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.)
Illnesses –
[Summary of relevant past medical history and co-morbidities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.)
**Examination**
"Ears Right:"
[Findings from the examination of the right ear, including appearance, discharge, and any other relevant observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.)
"Left:"
[Findings from the examination of the left ear, including appearance, discharge, and any other relevant observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.)
Audiogram –
[Results and interpretation of the audiogram] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.)
Diagnosis –
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Plan –
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"Thank you." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"Kind regards" (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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