H&P #2

Identifying data:

  • Date & Time: February 14, 2023 11:00 am
  • Full name: M. S.
  • Address: ——-
  • Date of birth: –/–/–
  • Location: Jamaica, NY
  • Source of information: Self
  • Reliability: Reliable
  • Source of referral: Self

 

Chief Complaint: “Right ear pain” x 4 days

 

History of Present Illness:

M. S. is a 22-year-old female with PMHx of asthma complaining of right ear pain x 4 days. Patient rates the pain 6/10 in severity. Patient states she recently had a sore throat and rhinorrhea that has resolved. States she has attempted to clean ears using OTC debrox and has been taking ibuprofen 400 mg PRN. Patient admits to muffled hearing and slight nasal congestion. Patient took 2 took at home COVID tests this morning, both were negative. Patient is vaccinated for COVID and influenza. Denies fever, sinus pressure, headache, nuchal rigidity, cough, discharge from ear, tinnitus, sick contacts, recent swimming.

 

Past Medical History:

  • Asthma

Past Surgical History:

  • No past surgical history

Medications:

  • Ventolin HFA (Albuterol) 90 mcg/actuation INH Q4-6h PRN
  • No herbal supplement use

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • Mother: Age 48, alive and well, PMHx DM 2
  • Father: Age 50, alive and well, no significant PMHx
  • Maternal grandmother: deceased at age 71 due to breast cancer
  • Paternal grandparents: unknown

Social History:

  • Smoking: non-smoker
  • Substance use: Reports social alcohol use. Denies drug use
  • Caffeine: Admits to caffeine use, 1 cup of coffee per day
  • Occupational history: student
  • Home situation: lives in apartment alone

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies head trauma, vertigo.
  • Eyes: Denies contacts/glasses use, visual disturbances, eyelid swelling, pruritus, photophobia, lacrimation. Last eye exam about 8 months ago.
  • Ears: Admits to ear pain. Denies deafness, discharge, tinnitus.
  • Nose: Admits to nasal congestion. Denies epistaxis, discharge.
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, hx of HTN, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Denies change in appetite, intolerance to specific foods, abdominal pain nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Menstrual/Obstetrical: G0, P(T0 P0 A0 L0), menarche age 14, LMP 2/10/23, regular menstrual cycles every 28 days. Denies hot flashes, vaginal discharge. Last pap smear exam 6/23/22, normal.
  • Sexual History: Admits to currently being sexually active with 1 male partner. Admits to condom use. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

Physical Exam:

Vitals:

  • BP: 121/74 (seated, right arm)
  • HR: 77 BPM (regular)
  • RR: 16/min (unlabored)
  • T: 97.3 F (oral)
  • O2: 100% (room air)
  • Height: 65in Weight: 129bs     BMI: 21.5

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: PERRLA. Visual fields full OU. EOM intact, no nystagmus. Sclera white, cornea clear, conjunctiva pink.

Ears: Right ear: Canal intact, no swelling or erythema. Mild amount of cerumen noted in canal. TM erythematous and bulging. No effusion present.  No discharge or foreign bodies noted. Auricle in good position. No mastoid tenderness.

Left ear: TM pearly grey and intact with light reflect in good position. No tenderness, discharge or foreign bodies.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink.

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender to palpation. No cervical lymphadenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Abdomen flat and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, nontender, no guarding or rebound noted. Negative CVA tenderness.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Female genitalia: exam not performed.

Rectal: exam not performed.

 

Differential Diagnosis:

  1. Acute otitis media
  2. Acute otitis externa
  3. Cerumen impaction
  4. Sinusitis
  5. Mastoiditis

 

Assessment:

M.S. is a 22yo female with PMHx of asthma complaining right ear discomfort and nasal congestion x 4 days. On exam, the patient is afebrile and there is erythema and bulging of the right TM noted. The auricle is nondisplaced and there are no signs of effusion or perforation. Symptoms and signs are consistent with acute otitis media.

 

Diagnosis: Acute otitis media

 

Plan:

  1. Start amoxicillin 875mg-clavulante 125mg (Augmentin) BID x 10 days
  2. Pain relief – use OTC Ibuprofen or Tylenol PRN
  3. Nasal congestion – Fluticasone Flovent HFA: 110 mcg/actuation (12 g) BID PRN
  4. Ear hygiene: Avoid cotton swabs. Clean ears gently in shower with damp washcloth. For built up earwax use over the counter debrox ear drops.
  5. Follow up if: severe ear pain, pus or blood draining from ear