1st ENT Consult

Date: 01/11/2024 PATIENT DEMOGRAPHICS Name: John Doe DOB: 15/05/1980 Age: 44 Gender: Male Referred by: Dr. Sarah Smith PRESENTING COMPLAINT Persistent ear pain and hearing loss in the right ear. HISTORY OF PRESENTING COMPLAINT Duration: 3 weeks Site: Right ear Onset: Gradual Character: Dull, aching pain Radiation: None Associated symptoms: Occasional tinnitus Aggravating factors: Loud noises Relieving factors: Rest ENT SPECIFIC SYMPTOMS Ear: - Pain: Persistent dull ache in the right ear - Discharge: None - Hearing loss: Notable in the right ear - Tinnitus: Occasional ringing in the right ear - Vertigo: None Nose: - Obstruction: None - Discharge: None - Epistaxis: None - Smell disturbance: None - Facial pain/pressure: None Throat: - Sore throat: None - Dysphagia: None - Voice changes: None - Snoring/sleep apnoea: None PAST MEDICAL HISTORY Hypertension PAST SURGICAL HISTORY Appendectomy in 2005 MEDICATIONS Current: Lisinopril 10mg daily Allergies: Penicillin SOCIAL HISTORY Smoking: Non-smoker Alcohol: Occasional Occupation: Accountant FAMILY HISTORY Father with a history of hearing loss EXAMINATION General appearance: Well-nourished, alert Ear examination: Right: Redness and swelling observed, reduced hearing Left: Normal Nose examination: External: Normal Anterior rhinoscopy: Normal Posterior rhinoscopy: Normal Oral cavity and oropharynx: Dentition: Good Tongue: Normal Tonsils: Normal Posterior pharyngeal wall: Normal Neck examination: Lymph nodes: No enlargement Thyroid: Normal INVESTIGATIONS Audiogram showing mild conductive hearing loss in the right ear IMPRESSION Right ear otitis media with effusion PLAN - Prescribe amoxicillin 500mg TID for 7 days - Follow-up in 2 weeks - Consider ENT referral if no improvement Dr. John Doe ENT Consultant ICD 10 codes: H66.9