Identifying Data:

Name: ID

Sex: Male

Address: New York

Age: 45 y/o  

Date & Time:

Location: Centers Urgent Care

Marital Status: Married 

Religion: Christian

Race: Hispanic

Source of Information: Self

Reliability: Reliable

Mode of Transport: Self  

Chief Complaint: “My left ear is clogged” x2 days

History of Present Illness:

ID is a 45 y/o reliable man, with no past medical history, who presents to the clinic with a complaint a left clogged ear for two days. Patient states that he woke up with his left ear feeling full. Patient states that this progressed to pain in his left ear. The patient rates the pain a 6/10 and characterizes it as a sharp pain. Patient states that the pain does not radiate anywhere. Patient has taken Tylenol which seems to have helped the symptoms slightly. Patient states that it is worse when he touches his left ear and when he tries to put in headphones. Patient admits to fever last night (100.6 F) and aural fullness. Patient states that he developed a mild headache but it also resolved with the Tylenol. Patient denies tinnitus, hearing loss, dizziness and imbalance. Patient denies right ear pain. Patient denies chills, nausea, vomiting and diarrhea. Patient has not traveled anywhere recently and also has not been in contact with anyone who has been sick.

Past Medical History:

Present medical illnesses – None  

Childhood illnesses – none

Immunizations – Up to date with the flu vaccine and the TDAP vaccine. Due for the second COVID vaccine 10/25/21.

Past Surgical History:

Denies any past surgical history

Medications:

None

Allergies:

Allergic to Pineapple, will have a rash if eaten.

Family History:

Denies any family history of cancer.

Social History:

ID is a 45 y/o married man who lives in an apartment with his wife and 3 children. Patient states that he does not drink alcohol or smoke cigarettes, e-cigarettes or hookah. Patient is a construction worker. Patient drinks 2-3 cups of coffee a day.  Patient gets 6 hours of sleep a night. Patient eats a normal diet.

Review of Systems:

General – Admits to headache and fever. Denies loss of appetite, recent weight gain or loss, generalized weakness/fatigue, or night sweats.

Skin, hair, nails – Denies rash, changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Admits to headache. Denies dizziness, vertigo or head trauma, head fracture or coma.

Eyes – Denies photophobia, eye pain, pruritus, and tearing. Denies contacts or glasses. Last eye exam x3 year ago- normal.

Ears –Admits to left ear pain, and aural fullness. Denies tinnitus, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Pulmonary– Denies dyspnea, DOE, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis and hemoptysis.

Cardiovascular–Denies chest pain or shortness of breath. Denies swelling of the extremities, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal-  Denies flatulence, eructation, acid reflux and blood in the stool. Denies change in appetite, intolerance to specific foods, vomiting, nausea, constipation, dysphagia, pyrosis, abdominal pain, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency, urgency, slight incontinence and nocturia. Denies oliguria, polyuria, dysuria, or flank pain.

Sexual History-  Patient admits to being currently sexually active. Partners were always female. Denies history of sexually transmitted diseases and impotence.

Physical Exam

General: 45  year old female, alert and oriented to person, place and time.  Patient in no apparent distress. Patient appears to be his stated age, is well developed, has good posture, is well dressed, well groomed, has good hygiene.

Vital Signs:      

                        BP: 132/83

R: 18 breaths/min unlabored     

P: 100 beats/min, regular      

T:99.7 degrees F (temporal)              

O2 Sat: 98% on Room air

Height: 5’7”               Weight: 197 pounds       

Eyes

The left eye is positive for discharge, redness and stickiness. Patient was not able to open the left eye do to extreme pain so was not able to perform any tests. The right pupil was round and reactive to light, conjunctiva and cornea is clear. No redness, discharge or stickiness was noted. Right eye had proper extraocular movements.

Ears

Symmetrical and normal size. Left ear canal is positive for edema and erythema with exudate. Right ear canal is clear with mild cerumen. No lesions, masses or trauma on external ears. No foreign bodies in external auditory canals AU. Tenderness upon palpation of the tragus. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies. 

Mouth

Moist mucous membranes without erythema or exudate. Patient had all of her teeth.

Neck

Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. No palpable adenopathy noted.

Thyroid

Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. No tenderness to palpation. 

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus throughout. No adventitious sounds.  

Heart

Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

DDX:

1. Acute Otitis Externa
   1. Pain external canal
   1. Fever
   1. Pain exacerbated with palpation of the tragus
   1. Erythema and edema of the left ear
2. Ear canal trauma
   1. Pain in external canal
   1. Erythema and edema of the left ear
3. Furunculosis
   1. Pain in external canal
   1. Erythema and edema of the left ear
4. TMJ
   1. General pain around the ear
5. Foreign body in the ear
   1. Pain in the ear
   1. Edema and erythema of the canal

Assessment – ID is a 45 y/o reliable man, with no past medical history, who presents to the clinic with a complaint a left clogged ear for two days

Plan:

1. Acute diffuse otitis externa of the left ear
   1. Start Ciprodex suspension, 0.3-0.1%, 4 drops into the affected ear, twice a day, for ten days.
2. Discharge instructions reviewed and discussed with the patient
3. Continue medication as prescribed, side effects reviewed and discussed
4. Avoid getting the ear wet until symptoms fully resolve and treatment completed.
5. Patient advised to proceed to ER if pus or blood drains from ear, spike in fever, redness behind the ear, ringing in the ear, dizziness, loss of hearing or other concerning symptoms arise.
6. Patient advised to follow up with PCP