Focused H&P#2

Daniel DeMarco Focused H&P#2 Ambulatory Care

Chief Complaint: Left Ear Fullness x 3d

 

History of Present Illness:

KS is a 25yo Female presenting to office with complaint of Left Ear Fullness since x 3d. Patient states she was at the beach on Friday when she was knocked down by a wave and she felt water rush into her ear. The fullness started at that time. Patient states that she began having mild Left Ear Pain that started the following day. It is worsening. Patient tried OTC “Swimmer’s Ear” drops with no relief. Admits decreased hearing in Left Ear. Denies fever, chills, nausea, vomiting, headache, tinnitus, discharge.

 

Allergies: NKDA

Medications: Denies

PMH: Denies

PSH: Denies

Social History: Admits social EtOH use. Denies tobacco use, marijuana use, other illicit drug use.

Family History: Denies

 

Review of Systems:

General: Denies fever, chills, anorexia, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Admits Left Ear Pain. Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, congestion, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, history of murmur, fainting, or dizziness with activity 

Respiratory: Denies wheezing, shortness of breath, cough

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Denies HI/SI, feelings of helplessness, hopelessness

 

Physical Exam:

Vital Signs:

BP: 110/72

Pulse: 64bpm

RR: 16 breaths/min

Temp: 37.2C

SpO2: 100%RA

Ht: 64.0 inches

Wt: 51kg

 

General Survey: Alert, NAD. Appears stated age.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Head: NC/AT. Non-tender to palpation throughout. Frontal and maxillary sinuses nontender to palpation and percussion.

Eyes: PERRLA. EOM intact and nonpainful. Red reflex present bilaterally. No crusting on lashes. No discharge.

Ears: External ear with no masses, lesions. Nontender to palpation. Left Canal with moderate injection. Several small circular masses in the ear that may represent sand or gravel. Right Canal without injection, masses. B/L TMs pearly gray with cone of light in appropriate position.

Nose: Nares patent. Mucosa pink. Septum midline. Turbinates non-boggy, non-hyperemic.

Throat: Oropharynx without erythema. Good dentition. Gingiva without lesions, masses. Uvula midline. No tonsillar swelling. 

Neck: Supple. No thyromegaly. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

 

Assessment/Plan:

KS is a 25yo Female with 3d complaint of left ear fullness, pain, and decreased hearing consistent with otitis externa.

 

#Left Ear Otitis Externa

– Warm Water Flush performed to remove sand/gravel

– Start Ciprofloxacin 0.2% and Hydrocortisone 1% Otic Suspension (Cipro HC Otic) 3 gtt in ear bid x 7d

– If worsening ear pain, deafness, or other symptoms go straight to ER

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student