Ear Pain

HISTORY:

‍RightLeft earache for ‍ ‍hoursdays

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Pattern: ‍constantintermittent

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective

‍ear discharge

‍hearing loss

‍clogged sensation

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍nasal congestion

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍sore throat

‍headache

‍tinnitus

‍vertigo



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: ‍normocephalicatraumaticnormal scalprashlesion

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy



ASSESSMENT:

‍Acute otitis media ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Audiogram

- Blood work: ‍CBC, ‍CRP

- Ear swab for culture

- ‍Analgesics

- ‍Ear drops

- ‍Topical antibiotics

- ‍Oral antibiotics

- ‍Nasal Steroids

- ‍Decongestants

- Warm compresses

- Avoid swimming

- Avoid q-tips

- Referral to otolaryngologist

- Referral to dentist for ATM dysfunction

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as hearing loss, fever, or discharge from the ear