H&P  

  

History  

Identifying Data:  

Full Name: SS

Address: N/A  

Date of Birth: N/A  

Date & Time: 05/12/23 9:00am  

Location: CUC

Religion: N/A  

Source of Information: Self  

Reliability: Reliable  

Source of Referral: Self  

Mode of Transport: N/A  

Chief Complaint: “I have left ear pain” x 2 days.

38 y/o M with no PMH presenting for left ear pain x 2 days. Pt reports he woke up Saturday morning with left ear discomfort, but he’s had issues with ear wax build up in the past, so he used OTC ear wax “conditioner.” He states he was doing well until later that afternoon when he suddenly developed severe ear pain that he rates as 9/10. He used some Motrin which gave him some relief. The following day he noticed some yellow discharge coming out of the ear and reports he was awoken from sleep due to pain later that night. Pt now complaining of hearing loss and ear fullness. Pt also notes he had recently been treated here ~ 1 week ago with Amox for possible strep, but had an allergic reaction and now being treated with steroids and Z-pack. Denies fever, chills, nausea, vomiting, diarrhea, ringing of ears, SOB, chest pain, or recent sick contacts. 

Initial DDx:  

Fungal Otitis Externa

Otitis Media

Cerumen Impaction

Melting Cerumen

Eczema

Early Ruptured Acute Otitis Media

Past Medical History:  

Childhood Illnesses- N/A  

Immunizations – Up to date; flu vaccine yearly

Screening test and results – N/A 

Past Surgical History:  

No past surgical history. 

Denies any blood transfusions.  

  

Medications:  

Not on any medications at this time.

Allergies:  

Amoxicillin – hives

  

Family History:  

Mother – 64 y/o, alive and well

Dad – 65 y/o, alive and well

Maternal/paternal grandparents – Alive and well.

Denies family h/o diabetes and cancer. 

  

Social History:  

Patient lives with wife. 

Habits –No history of smoking, alcohol abuse, or history of illicit substances. Drinks one cup of coffee a day. 

Travel – No recent travel.  

Diet – Has a well-balanced diet.  

Exercise – Denies exercise. 

Safety measures – Admits to wearing a seatbelt.  

Sexual Hx – Pt is heterosexual. Denies history of sexually transmitted diseases.

Review of Systems:  

General – Denies recent weight loss or gain, chills, night sweats, loss of appetite or generalized weakness/fatigue.  

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

Head – Denies headache or head trauma.   

Eyes – Denies lacrimation, pruritus, visual disturbances. Does not wear glasses.

Ears – Admits to ear pain, muffled hearing and discharge. Denies deafness, tinnitus or use of hearing aids.   

Nose/sinuses –Denies discharge, epistaxis, or nasal polyps.  

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion   

Breast – Denies lumps, nipple discharge, or pain.   

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. 

Pulmonary system – Positive for cough. Denies dyspnea on exertion. Denies wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).   

Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.  

Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.   

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

Menstrual/Obstetrical – N/A 

Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.  

Nervous –Hx of febrile seizures. Denies loss of strength or weakness. Denies headache, ataxia, change in cognition.   

Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.   

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.  

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter   

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.   

  

Physical  

  

General: Female appears clean & casually-groomed, alert & active. Also has good posture and well-developed. Does not appear to be in acute distress.

  

Vital Signs:     P:  86 beats/min, regular  

   

R: 18 breaths/min, labored

O2 Sat: 99% on room air 

  

T: 36.9 degrees C (oral)  

  

Weight: 86.3 kg 

  

Head, Skin, & Nails  

  

Hair: Average quantity and distribution. Brown color. Straight texture. No evidence of lice or seborrheic dermatitis.  

Skin: Warm and moist, smooth texture, good turgor.   

Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities  

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

  

Eye Exam  

  

Eyes – No strabismus, exophthalmos, or ptosis.  Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/0 OS, 20/20 OD,  20/20 OU. Visual fields full OU.  PERRLA, EOMs intact with no nystagmus.    

  

Ear Exam  

  

External ears symmetrical and appropriate size with no evidence of lesions, masses or trauma. Left ear: TM erythematous, milky white discharge noted in external auditory canal, no external canal erythema or edema noted, no gross foreign body noted, no mastoid redness, swelling or tenderness noted. Right ear: No foreign body in external auditory canal. TM pearly gray/infarct with light reflex in good position. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.  

  

Nose & Sinuses Exam  

  

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

  

Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.  

  

Mouth & Pharynx  

  

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.  

Mucosa – Pink ; well hydrated. No masses; lesions noted.   Non-tender to palpation. No leukoplakia.   

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.  Non-tender to   

Palpation; continuity intact.   

Teeth – Good dentition / no obvious dental caries noted.   

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.  

Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.  
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.   

Tonsils present with no injection or exudate. Uvula pink, no edema, lesions  

  

Neck Exam  

  

Neck– Trachea midline.   No masses; lesions; scars; pulsations noted.   Supple; non-tender to  

palpation.   FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.  

  

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

  

Thorax & Lungs:   

  

Chest – Symmetrical, no deformities, no trauma, Respirations unlabored and no use of accessory muscles noted. Non-tender to palpation throughout. 

  

Lungs – No wheezing, rales, stridor, or rhonchi. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.    

Cardiac Exam  

  

Heart: PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.  

  

Abdominal Exam: Abdomen flat and symmetric, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.  

  

Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge.   

  

Pelvic Exam: N/A

Rectal: N/A

  

Neurologic:  

Mental status: Patient is alert. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally. 

Reflexes:  

  

	Biceps	Triceps	Brachioradialis	Patellar	Ankle/Achilles	Babinski
Right	2+	2+	2+	2+	2+	absent
Left	2+	2+	2+	2+	2+	absent

  

Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted.  

  

Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /  

ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.    

Differential Diagnosis After: 

Otitis Media with superimposed Fungal Otitis Externa

Assessment:  

38 y/o M with no PMH with left ear discomfort and muffled hearing. Exam with milky white discharge and erythematous TM. Given recent prophylactic treatment with antibiotics for possible strep and steroids for recent allergic reaction to Amoxicillin consider Otitis Media with superimposed Fungal Otitis Externa.

Plan: 

Continue current medication, Z-pack, as prescribed. Side effects discussed and reviewed with patient. Start Clotrimazole 1% applied externally twice a day for 10 days. Discussed avoiding getting ear wet until symptoms fully resolve and treatment completed. Pt advised to proceed to ER if pus or blood drains from ear, spike in fever, redness behind ear, ringing in ear, dizziness, loss of hearing or other concerning symptoms arise. Pt advised to follow up with PCP and ENT.