Ear Pain

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍rightleft earache

Rated at ‍012345678910 / 10 ‍

Described as ‍dullaching

Pattern ‍persistentintermittent

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍ear discharge

‍hearing loss

‍clogged sensation

‍tinnitus

‍vertigo

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍nasal congestion

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍sore throat

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍facial pain



Contributing factors:

‍allergies

‍swimming

‍diving

no history of: ‍otitis media, ‍otitis externa, ‍temporomandibular joint dysfunction, ‍ear surgery, ‍diabetes, ‍immunodeficiency





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Head: ‍normocephalicatraumatic, scalp ‍normalrashlesion

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍





ASSESSMENT:

‍Acute otitis media ‍likelysuspectedpossible

DDx: acute otitis media, serous otitis media, otitis externa, Eustachian tube dysfunction, temporomandibular joint disorder, dental abscess, pharyngitis, cervical lymphadenopathy, sinusitis, mastoiditis, foreign body in the ear, neuralgia, barotrauma, herpes zoster oticus, malignant otitis externa





PLAN:

Investigations:

- Audiogram

- Blood work: ‍CBC, ‍CRP

- Ear swab for culture

Treatments:

- ‍Analgesics

- ‍Ear drops

- ‍Topical antibiotics

- ‍Oral antibiotics

- ‍Nasal Steroids

- ‍Decongestants

- Warm compresses

- Avoid swimming

- Avoid q-tips

Further care:

- 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