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Ear Pain
HISTORY:
Right
Left
earache for
days
Severity:
mild
moderate
severe
,
0
1
2
3
4
5
6
7
8
9
10
/ 10
Pattern:
constant
intermittent
Worsening factors:
none
Treatments tried:
none
,
effective
ineffective
ear discharge
hearing loss
clogged sensation
fever
chills
nasal congestion
cough
sputum
sore throat
headache
tinnitus
vertigo
Other elements:
allergies
swimming
diving
otitis media
otitis externa
temporomandibular joint dysfunction
ear surgery
diabetes
immunodeficiency
EXAM:
General appearance:
well-appearing
Vital signs:
normal
,
BP
,
HR
,
RR
,
SpO2
%
,
Temp
°
Head:
normocephalic
Eyes: -R:
normal
, -L:
normal
,
Ears: -R:
normal
, -L:
normal
Nose:
normal
Throat:
normal
Neck:
normal
Lungs:
clear
,
retractions
ASSESSMENT:
Acute otitis media
likely
suspected
possible
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
days
weeks
- Return if symptoms worsen or if new symptoms develop such as hearing loss, fever, or discharge from the ear