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4 months ago

791 words

Visit Date: 01/16/2019


Patient: Ms. J

Age: 22

Race: White

Informant: Pt herself, reliable


CC: “Ear pressure” x2 days


HPI: 22 y/o Female presenting to clinic /c no PMH c/o of right ear pain and pressure and x 2 days. Patient states pain behind suddenly and was unable to sleep last night. On a scale of 1-10, patient rates pain right now as a 6. She admits feeling feverish, sweaty and nauseous. She reports mild hearing loss in Right ear. She is also complaining of mild nasal congestion and sore throat for x3 days. Patient took ibuprofen with mild relief. This has never happened before. Patient denies chills, night sweats, CP, SOB, v/d, abdominal pain, loss of appetite, discharge from ear, ringing.


PMH: None


PSH: C-section 2017 no complications


PH: None


Meds: Vitamin D


Allergies NKDA



  • Up to date
  • Flu shot 2018

Family History

  • Mother-alive, well
  • Father-alive CAD

Social History

  • Caffeine/smoking: None
  • Denies drugs, smoking/tobacco/illicit drug use
  • Alcohol: Socially, 2 beers per night for x1 weeks
  • Employment: Manager
  • Marital Status: Married, sexually active with husband, uses protection
  • Children: 1
  • Occupation: Bank teller




General: Denies fever, night sweats, chills fatigue, weakness

Skin, hair, nails: Denies lesions, rashes, sores, pruritus

Head: Denies h/a, vertigo, lightheadedness

Eyes: Denies glasses, blurring or recent visual disturbances


Noses/sinuses: Denies discharge, epistaxis, obstruction

Mouth/throat: Admits sore throat. Denies bleeding gums, sore tongue, mouth ulcers

Neck: Denies localized swelling/lumps, stiffness or decreased ROM

Breast: Denies lumps, nipple discharge, pain

Cardiac: Denies murmurs, palpitations, DOE, orthopnea, CP

Respiratory: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, PND

GI: No appetite changes. Regular BMs. No blood in stool .

GU: Denies urgency, dysuria, changes in frequency, hesitancy, dribbling

MSK: Denies arthralgias, swelling, joint pain or back pain

Peripheral Vascular: Denies claudication, trophic changes, peripheral edema

Heme: Denies anemia, easy bruising or bleeding, lymph node enlargement

Endo: Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, goiter, hirsutism

Nervous: Denies seizures, tingling/numbness, sensation changes.

Psych: Denies little interest or pleasure in doings things. No feelings of depression or hopelessness



General Appearance: Alert and oriented. Appears her age. Small frame. Good hygiene and grooming. Good posture and gait. Patient in no acute distress.



Temp: 99.1 F

HR: 71 bpm, RRR

BP: sitting 112/70 Right arm

Ht:  67”

Wt:  150#

BMI: 23.49 kg/m^2

RR: 16 breaths per min, unlabored

O2 Sat: 100

Pain Scale: 6


Skin: Warm and moist, good turgor, nonicteric, no lesions, scars or tattoos

Hair: Average quantity and distribution

Nails: cap refill <2 secs. No clubbing present

Head: normocephalic, atraumatic, Non tender to palpation

Eyes: Not assessed

Ears: External appearance normal w/o lesions, redness, swelling. Otoscopic exam Right Ear TM erythematous, fluid noted behind TM. Decreased acuity in the right ear

Nose: Appearance normal with no mucous, inflammation or lesions present. Nares patent. Septum midline and

Sinuses: Non tender to palpation

Neck/Throat: Neck normal in symmetry w/o masses. No inflammation or lesions present.

Heart: RRR, Normal S1, S2. No murmurs heard. PMI in 5th ICS midclavicular No heaves, thrills noted

Lungs: Clear to percussion and auscultation bilaterally. No crackles, rhonchi, rales. No use of accessory muscles noted. Non tender to palpation bilaterally. Negative increase in tactile fremitus throughout.

Breasts: Not assessed

Abdomen: Symmetrical, ND/NT. BS present in all 4 quadrants. No bruits. Tympany to percussion throughout. Non tender to palpation. Neg CVAT bilaterally

GU: Not assessed

Rectal: Not assessed

Peripheral Vascular: Pulses normal, no cyanosis no edema.

MSK: Not assessed

Neuro: CN 1-12 normal




  1. Otitis Media
    1. + low grade fever
    2. +pain in Right ear, decreased hearing
    3. +fluid noted
  2. URI
    1. + low grade temp
    2. +Congestion could be viral
    3. No respiratory symptoms, such as cough, sore throat
  3. Sinusitis
    1. +Low grade temp
    2. -Has fluid behind ear and redness in ear canal
    3. -No nasal drainage, or redness of throat or sinus tenderness


Labs/Testing: none


Assessment & Plan

22 y/o F presents to clinic c/o of Right ear pain and pressure x2 days. Pt admits to loss of hearing in right ear, fullness, nausea, subjective fever. Pt has low grade fever, TM erythematous and bulging, with fluid. Patient findings more consistent with otitis media.



  1. Otitis Media
    1. Amoxicillin 875 mg po TID x 10 days
    2. Tynenol/Acetaminophen 500 mg tabs 2 po q 4 hours prn fever/pain


Patient Education

Generally, not serious if promptly and properly treated. With aid of provider, you can feel better and hear properly very soon. Be sure to follow treatment plan and see through care until condition fully taken its course. Increase fluids, rest. Follow up in 7 days. Return to clinic if fever continues, or sooner if increase in pain, h/a, vomiting, or worsened condition. Take care of your ears, dry ears after shower.

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