Complete Notes and SOAP notes

Acute Otitis Media / Ear Pain

HPI:

Natalia is a healthy 22 yo Female with frequent otitis media, who presents with ear pain, facial pain, and neck pain. She states that the ear pain is new. Her neck and facial and jaw pain have been ongoing for at least a week.

She states that she has bad ear pain with ringing and decreased hearing in her right ear. Hearing is normal in her Left ear. She woke up with a Sore Throat today. She gets about 3-4 ear infections per year. She has always had difficulty equalizing the pressure in her ears.

Med Hx: ***

options: Never smoker
Smokes infrequently/socially
Smokes 1/2 PPD

Allergies: ***

Medications: ***

No recent antibiotic use.

ROS:

GENERAL: Denies fever, chills, night sweats, poor appetite.
EYES: Denies visual changes.
EARS: Complains of pain/pressure in Left/Right ear and muffled hearing.
RESP: Denies shortness of breath, cough.
CV: Denies chest pain, palpitations, leg swelling.
GI: Denies nausea, vomiting, diarrhea, abdominal pain - although she says perhaps a mild diarrhea.
GU: Denies dysuria, burning, urgency, and frequency.
MSK: Denies swelling, joint pain, and stiffness.
NEURO: Denies headache, weakness, numbness, and tingling.
DERM: Denies rashes
All other systems were reviewed and are negative.

PE IS FROM CP - all else should be done, but could be combined with other stuff I have for AOM

Physical Exam:

GENERAL: NAD, speaking full sentences
VSS, afebrile
GI: Pt is tender over McBurney's point, right adnexal tenderness, AND a positive Murphy's sign. No HSM. No suprapubic tenderness or distention. No CVAT. Flat without distention. No surface trauma, scars, incisions or rash. +BS.
SKIN: PWD, no diaphoresis, cyanosis or pallor
EYES: pupils PERRL and EOMI
PULM: CTA bilaterally, no rales, rhonchi or wheezing
CV: RRR, no MGR
NEURO: A&O x 4, good insight and judgement

ASSESSMENT:

No clinical evidence of otitis externa, perforated TM, mastoiditis, or FB.

H66.91 Otitis media, unspecified, right ear
H66.92 Otitis media, unspecified, left ear

PLAN 1 (ABX prescribed):

Amoxicillin 500 mg oral tablet - take one tab oral three times a day for 10 days
Tylenol or Motrin for fever/pain
Consider use a heating pad on a low setting
To help prevent further infection, do not put anything in the ears, including cotton tipped applicators, because they can push wax back into the ear canal, causing wax buildup. The wax blocks the ear canal, making it hard to see the ear drum, leading to decreased hearing and infections.

RTC in 2-4 days
Pts parent understands and agrees with plan of care

PLAN 2 (ABX refused):

She refused antibiotics. I told her that antibiotics are the recommended course of action for inner ear infections. We compromised and I sent the prescription to her pharmacy and told her she should pick it up and it is there for her if she changes her mind.

I told her that to relieve the pain/pressure in her ears, she needs to decrease inflammation and open her Eustachian Tubes. She should drink plenty of water to thin your mucus, try OTC allergy medications and NSAIDs to reduce inflammation. Patient understands and agrees with plan of care.

To help prevent further infection, do not put anything in the ears including cotton tipped applicators, because they can push wax back into the ear canal, causing wax buildup. The wax blocks the ear canal, making it hard to see the ear drum, leading to decreased hearing and increased risk for infections.