Name: S.A.

Age: 20 (F)

PC – Left-sided hearing loss x several weeks

HPC 

Previously healthy young female presents with progressive hearing loss in her left ear over the past month following an upper respiratory tract infection. Initially felt “blocked,” now completely unable to hear on the left. Denies ear pain, discharge, or dizziness. No history of trauma or noise exposure. Symptoms are non-fluctuating.

ROS

• GENERAL – ᵒ Fever, ᵒ Weight loss, ✓ Fatigue (post-viral)

• ENT – ✓ Hearing loss (left), ᵒ Tinnitus, ᵒ Otalgia, ᵒ Vertigo, ᵒ Discharge

• CNS – ᵒ Headache, ✓ Alert, ᵒ Focal signs

• RESP – ✓ Recent URTI symptoms (cough, nasal congestion, resolved)

• GI, GU, CVS, MSS, SKIN – Non-contributory

PMHx 

Unremarkable

PSHx 

None

DHx 

Not on regular medications

FHx 

No family history of hearing loss

Social History 

• Student

• No smoking, alcohol, or recreational drug use

• Lives at home, no known environmental hazards

Allergies 

Nil known

Physical Exam

Vitals –

BP: 110/72 | PR: 76 | RR: 16 | SpO₂: 99% | Temp: 36.7°C

Ears 

• Left: dull, retracted tympanic membrane, visible fluid line

• Right: normal

• No mastoid tenderness

• Tuning fork: Weber lateralizes to right, Rinne negative on left

• Nose/Throat – No congestion or discharge

• CNS – CNs intact

• Neck – No lymphadenopathy

Investigations

• Tympanometry: Type B curve (left)

• Audiogram: Conductive hearing loss (left)

• No signs of inner ear or retrocochlear pathology

Diagnosis

Otitis Media with Effusion (OME), Left Ear

Plan

1. Scheduled for grommet (ventilation tube) insertion

2. Pre-operative counseling and consent

3. ENT follow-up in 2 weeks

4. Hearing reassessment post-procedure