History

Identifying Data:

Full Name: Mrs G

Address: Not Disclosed

Age: 19 years

Date & time:5/13/2021 10:00 AM

Location: Statcare Astoria

Religion: Not disclosed

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Self

Chief Complaint: “ear pain” x5 days

History of Present Illness:

19 year old F with no significant PMHx complains of bilateral ear pain x5 days. L ear pain began 5 days ago, R ear pain began 3 days ago. Pain is sharp and described as 10/10. Associated with decreased hearing. Saw pediatrician 3 days ago and given amoxicillin 500 mg twice daily, taking as prescribed with no improvement.

Denies fever, chills, tinnitus, mastoid pain, nasal discharge or congestion, SOB, CP

Past Medical History:

Denies past medical history

Immunizations – UTD  

Past Surgical History:

Denies surgical history

Medications:

Amoxicillin 500 mg BID

No vitamins, herbal teas or supplements

Allergies:

NKDA

No known environmental allergies

No known food allergies, no shellfish or seafood allergies

Family History:

No pertinent family history

Social History:

Mrs G is a 19 year old female living in an apartment with her parents. Does not drink alcohol, smoke or vape

Travel-Denies recent travel

Sleep-Sleeps 7 hours per night

Review of Systems:

General-See HPI

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

Head – Denies head trauma, LOC, fracture

Eyes – Denies lacrimation, erythema

Ears – See HPI

Nose/sinuses – See HPI

Mouth/throat – Denies bleeding gums, mouth ulcers, voice changes. Last dental appointment 6 months ago

Neck – Denies lumps, swelling, decreased ROM

Pulmonary system – Denies SOB, dyspnea, cough, wheezing, hemoptysis, orthopnea, PND

Cardiovascular system –Denies CP, palpitations, irregular heartbeat, edema of LE, syncope

Gastrointestinal system-  Denies abdominal pain, intolerance to foods, nausea, dysphagia, vomiting,  diarrhea, constipation

Genitourinary – Denies frequency, dysuria, incontinence, nocturia, hematuria

Nervous –Denies seizures, loss of consciousness

Musculoskeletal– Denies joint pain, deformity, swelling

Hematological system –Denies bleeding, easy bruising, lymph node enlargement, blood transfusions

Vital Signs

HR: 107 BPM, regular

BP 134/85 L arm sitting

RR: 17 breaths/minute, unlabored

Temp: 98.1 degrees F oral

O2 Sat: 99% on room air

Ht 5’2’’

Wt 150 lbs

BMI 27.4

Physical Exam:

General: Uncomfortable appearing female, well groomed, non-toxic appearing, in no acute distress. Appears stated age.

Skin:   warm & moist, good turgor. capillary refill <2 seconds throughout. No jaundice or pallor. No petechiae or rash.

Hair:   average quantity and distribution

Head: normocephalic, atraumatic, no signs of injury

Ears – +canal swelling bilaterally, no erythema, cannot visualize TMs, no mastoid

tenderness bilaterally, pain with manipulation of the tragus and helix bilaterally, Right >

Left.

Eyes – symmetrical; sclera white; conjunctiva pink and moist, no discharge. PERRLA, EOMI

Nose –  Nasal mucosa moist. No rhinorrhea, congestion, masses, trauma, or deformities

Lips –  Pink, moist; no cyanosis or lesions.  

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate.  Uvula pink, no edema, lesions

Neck – FROM, supple, no rigidity. Trachea midline.   No masses; lesions; scars; pulsations noted. no stridor noted. no palpable adenopathy noted.

Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. No nasal flaring or retractions

Lungs – Clear to auscultation bilaterally, no adventitious sounds, wheezes or rhonchi.

Heart:   tachycardic, regular rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.

Abdomen: Bowel sounds normoactive in all four quadrants. Abdomen soft throughout, nondistended, no masses or hernias. Tympanic throughout.

Neuro: Alert, no focal deficit noted.

Assessment:

19 year old F with no significant PMHx complains of bilateral ear pain x5 days, external canals swollen cannot visualize TMs, no mastoid tenderness

Plan:

1. Ear pain
   • Otitis externa bacterial vs fungal
   • Given no improvement on amoxicillin will d/c and start abx with pseudomonas coverage
   • Start Ciprofloxacin HCl tablet 500 mg twice daily x7 days
   • Start ciprofloxacin-Dexamethasone suspension 0.3-0.1% 4 drops into each ear twice daily x7 days
   • Ear wick placed in R ear
   • Follow up in 2 days for re-evaluation and ear wick removal
   • OTC Tylenol prn pain or fever
   • Keep ear canal clean and dry, avoid Q-tip use
   • Return to clinic or go to ER if symptoms worsen