history provided by patient history provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

CC: earache pressure discharge hearing loss possible foreign body trauma bleeding ringing

AFFECTED EAR: right left both

HPI/SYMPTOMS: started today started yesterday started several days ago started more than 1 week ago started months ago started years ago still present increasing in severity persisting occasional decreasing resolved as in cc

MEDICATIONS: allergies reviewed, taking OTC taking RX reports no side effects reports side effects effective partially effective not effective demonstrates knowledge of medications/reasons/dosages unable to name medications/reasons/dosages none reported

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL:

objective fever subjective fever chills fatigue
EYES:

vision loss photophobia redness discharge lid swelling periorbital swelling pain with EOM
NOSE:

discharge PND congestion sinus pressure bleeding
MOUTH:

sores dryness tongue pain/swelling toothache
THROAT:

sore throat odynophagia dysphagia hoarseness
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure SOB palpitations dyspnea orthopnea ankle swelling ankle discoloration varicose veins leg cramps
CHEST/RESPIRATORY:

chest tightness pain w/ breathing cough wheezing
GI:

poor appetite nausea vomiting bloating heartburn gas abdominal pain constipation diarrhea
GU:

dysuria urgency odor hematuria hesitancy retention discharge
MSK:

neck pain back pain shoulder pain hip pain knee pain chronic pain/meds localized joint pain/deformity generalized joint pain localized muscle/soft tissue pain/swelling myalgias
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts seizures tingling/numbness
PSYCH:

irritability confusion depression anxiety mood swings memory loss insomnia
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia
ALLERGIES/IMMUNE:

atopy food allergies autoimmune dz h/o cancer
DERM:

dryness pruritus rash/redness swelling wounds new or suspicious lesions



OFFICE DIAGNOSTICS: none rapid strep NEG rapid strep POS rapid flu NEG rapid flu POS rapid C19 antigen NEG rapid C19 antigen POS rapid C19 antibody NEG rapid c19 antibody POS CXR

Appearance: well-appearing alert, non-toxic, normal WOB crying but consolable speaking in full sentences ill-appearing tired-looking short of breath diaphoretic drowsy appears impaired slumped heavy built muscular lean well-nourished frail

Skin: warm, dry, grossly intact, no rashes no bruises normal turgor dry tattoos body piercings pallor cyanosis poor turgor diaphoresis rash

Head/Face: normocephalic, atraumatic, symmetrical face CN grossly intact

Eyes: clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus, visual acuity grossly intact conjunctival injection epiphora conjunctival exudate allergic shiners dennie lines palpebral edema palpebral exudates glasses contacts

Nose: nares patent bilaterally, septum midline no facial tenderness mucosa pink & moist allergic salute maxillary tenderness frontal tenderness deviated septum mucosal edema clear discharge purulent drainage

Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements, moist oral mucosa without lesions upper denture lower denture poor dentition tooth decay single oral ulcer multiple oral ulcers gum swelling

Throat: normal voice, no stridor, patent pharynx w/o swelling or exudates uvula midline hoarseness inspiratory stridor muffled voice vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates pharyngeal crowding tonsilar enlargement tonsilar erythema tonsilar exudates tonsilar crypts tonsilar pustules

Neck: symmetric with free painless ROM, no masses noted no LAD anterior LAD posterior LAD

Chest: normal work of breathing, symmetrical chest expansion, chest wall atraumatic and non-tender no retractions clear and equal breath sounds bilaterally no axillary or supraclavicular LAD respiratory distress breath sounds decreased bilaterally coughing poor effort expiratory wheezing crackles regular rhythm no murmurs no ankle edema tachycardia irregular heart rhythm systolic murmur ankle edema varicosities stasis discoloration calf tenderness

Abdomen: normal visual inspection no distension protruding normal bowel sounds soft non-tender guarding diffuse tenderness over entire abdomen w/o RRG direct non-rebound tenderness hypoactive bowel sounds hyperactive bowel sounds not examined

GU: no suprapubic tenderness no CVAT bilaterally normal external genitalia not examined

MSK: no gross deformities, moves all extremities with good ROM for age, full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age

Neuro: normal concentration and attention memory grossly intact balance & coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical & grossly intact no involuntary movements or tremor tardive dyskinesia tics

Speech/Vocalization: normal for age clear & coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats insisting on particular medication, test, referral, or accommodation raising voice defensive/argumentative cursing/swearing previous providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity: calm, pleasant, respectful, cooperative with history & exam guarded anxious irritable frustrated labile agitated hostile forceful pacing fidgeting picking skin twirling hair cracking knuckles grimacing, furrowing eyebrows tightening jaw breathing hard intense staring threatening gestures fist-clenching withdrawn flat affect bradykinetic indifferent appears to be responding to internal psychotic process

Right Ear: auricle intact no mastoid tenderness no canal swelling no material present in canal no FB visible in canal normal TM pain w movement of auricle tragal tenderness canal swelling pustule in canal cerumen in canal dried up blood in canal FB in canal TM erythema TM dullness/loss of landmarks TM bulging TM perforation tube intact in TM fluid behind TM TM obscured by wax mastoid tenderness

Left Ear: auricle intact no mastoid tenderness no canal swelling no material present in canal no FB visible in canal normal TM pain w movement of auricle tragal tenderness canal swelling pustule in canal cerumen in canal dried up blood in canal FB in canal TM erythema TM dullness/loss of landmarks TM bulging TM perforation tube intact in TM fluid behind TM TM obscured by wax mastoid tenderness

DX:
acute otalgia
hearing loss
otitis externa
impacted cerumen
otitis media
otitis media w effusion
foreign body to ear
perforated TM
URI
TMJ syndrome

Discussion:

.
PLAN OF CARE: patient/family verbalized understanding of dx & POC, agreed with dx & POC did not agree with dx & POC – encouraged to seek second opinion

PROCEDURE: N/A attempt to remove cerumen using curette was unsuccessful attempt to remove FB w forceps was unsuccessful liquid medication instilled ear lavage completed by MA reexamined by provider canal clear, TM intact no FB present no active bleeding tolerated procedure well

ORDERS - MA: injection Rocephin 1 gm IM now Dexa 8 mg IM now none

ORDERS - RX: OTC electronic paper given to MA to be transmitted to pharmacy none

ORDERS - LABS: CBC CMP UA c19 PCR none

ORDERS - IMAGING: X-ray US MRI none

ORDERS - FORMS: POC test results excuse accomodations clearance return to school/work school/participation physical none

REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct (re)evaluation and/or contacting emergency services, medications previous visits laboratory/diagnostic studies expect call from clinic for any abnormal diagnostic studies contact clinic for diagnostic results if not received call specialty reports hospital discharge medication compliance bringing all medications/labels to all visits home BP checks home BS checks daily weights controlling chronic conditions age-appropriate screening and immunization annual eye exam

DISCHARGE CONDITION/SAFETY: improved stable unchanged appears well non-toxic physical exam unremarkable for any emergent condition no safety concerns at this time safety concerns d/t depressed agitated mood safety concerns d/t impulsiveness safety concerns d/t hostile temper safety concerns d/t past attempts safety concerns d/t current suicidal verbalization

DISPOSITION: home quarantine 10-14 days referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left exam room before visit conclusion asked to leave clinic

FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, here in-person televisit w PCP 24 hours 2-3 days 1 week f/u acute episode f/u labs f/u imaging f/u med change/new

BARRIERS TO CARE: incomplete history poor cooperation with exam language barrier affect socio-cultural factors vague shifting complaints history not supported by objective findings supporting documentation unavailable poor compliance with POC intolerance of/therapeutic failure on multiple meds negative attitude to diagnostic impression & proposed tx lack of interest in nonpharmacologic therapies preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others hostile/disruptive behavior none noted at this time

Result - Copy and paste this output: