Demographics:
Name: LN
DOB: 2021
Date 6/3/21
Location: NYPQ
Address: Queens
Race: Hispanic
Source: Self
CC: Left sided ear pain x 2 days.
HPI: Ms. LN is a 21 y/o Hispanic female with no PMHx who presents with left sided ear pain x 2 days. She states the pain was sudden on onset, and constant. She has not tried anything to relieve the pain and rates the pain as 8/10. Patient admits to pain with opening and closing her jaw, decreased hearing in the left ear, discharge from her left ear, and itchiness of the left ear. She denies recent swimming, being in a body of water or sticking anything into her ear, recent trauma, fever, chills, recent colds, nausea, vomiting, blurry vision or eye pain.
Review of Systems:
General: Denies night sweats, fatigue, weakness and recent weight gain or loss.
Skin, Hair, Nails: Denies change in texture, excessive dryness, sweating, rashes/moles, discolorations, or pruritis.
Head: Denies headache, vertigo, head trauma, loss of consciousness or coma.
Eyes: Denies lacrimation, photophobia, fatigue, photophobia or pruritus.
Ears: Denies deafness, tinnitus.
Nose/sinuses: Denies discharge, epistaxis or obstruction.
Mouth and throat: Denies bleeding gums, sore throat, sore tongue, mouth ulcers.
Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast: Denies lumps, nipple discharge or pain.
Pulmonary System: Denies dyspnea, shortness of breath, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.
Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, or syncope.
Gastrointestinal System: Denies changes in appetite, intolerance to foods, dysphagia, pyrosis, excessive flatulence, eructation, jaundice, constipation, rectal bleeding, or hematochezia.
Genitourinary: Denies nocturia, urgency, oliguria or polyuria.
Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral Vascular System: Denies intermittent claudication coldness, varicose veins, peripheral edema or color change.
Hematologic System: denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE.
Endocrine System: Denies polydipsia, polyphagia, polyuria, heat or cold intolerance, goiter or hirsutism.
Nervous System: Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesia, hyperesthesia), ataxia, loss of strength, changes in cognition/mental status/memory or weakness.
Psychiatric: Denies Anxiety, loss of interest in previously enjoyed activities, or depression.
Past medical history: none
Past surgical history: none
Family Hx: unknown
Social Hx: lives at home
Smoking: never smoked
Alcohol use: none
Illicit drug use: denies illicit drug use
Medications: none
Allergies: no known drug, food or environmental allergies
Immunizations: Up to date with childhood vaccines
Vitals:
Temperature: 37.5 degrees Celsius (oral) (99.5 degrees Fahrenheit)
Heart Rate: 78
SpO2: 97% room air
Respiratory rate: 18 unlabored
Blood pressure: 137/85 left arm seated.
Weight (kg): 60.3
Height: 150 cm
BMI: 26.8
Physical Exam:
General: Alert, awake and oriented to person, place and time. Not in acute distress.
Skin: Warm and moist, good turgor. No scars or lesions noted.
Hair: Average quantity and distribution.
Head: Tender to left mastoid region. Atraumatic, no deformities.
Eyes: PERRLA, sclera white, conjunctiva clear, no eye discharge.
Ears: Right ear non-erythematous, no discharge, tympanic membrane visible with cone of light at 5 o’clock. Left pinna is non-erythematous. Left external ear with tenderness surrounding the ear with auricular lymphadenopathy. Swelling and visible discharge noted in the left auditory canal. Tympanic membrane unable to visualize AS due to swelling.
Nose: No masses, lesions or discharge noted.
Mouth: Lips pink and moist. Mucosa pink and well hydrated. No masses or lesions. Palate pink and well hydrated. Teeth good dentition. Gingivae pink and moist without deformities. Tongue pink does not deviate. Oropharynx well hydrated, no exudate.
Neck: Trachea midline. 2+ carotid pulses. No adenopathy noted.
Thyroid: no palpable masses, not enlarged.
Chest: Rises symmetrical, respirations unlabored. Lat to AP diameter 2:1. Non-tender to palpation.
Lungs: clear to auscultation, no adventitious lung sounds.
Heart: S1 and S2 present. Regular rate and rhythm. No murmurs noted.
Abdomen: Non-distended. No masses, lesions, or scars. Normoactive bowel sounds in all four quadrants.
Musculoskeletal: full range of motion of neck, trunk and extremities. No joint swelling.
Laboratory:
LABS (last 24h) ( 03 Jun 2021)
137 | 102 | 5.7
——————–< 80 Ca: 8.8 Anion Gap: 11 [06/03 @ 12:45]
3.9 | 24 | 0.40
WBC: 12.01 / Hb: 11.2 (MCV: 87.6) / Hct: 33.9 / Plt: 232 [06/03 @ 12:45]
— Diff: N:80.4% L:11.80% Mo:6.2%.
Radiology:
Age: 21 years Sex:F
Pt Loc: Emergency Dept
6/3/2021 12:05 EDT CT HEAD/BRAIN W/O CONT
Reason For Exam
(CT HEAD/BRAIN W/O CONT) L ear otitis externa
REPORT:
Reason for examination : Left otitis externa.
Comparison: None
Technique: Multiple CT axial images were obtained without contrast.
This CT exam was performed using one or more of the following dose
reduction
techniques: Automated exposure control, adjustment of the mA and/or kV
according to patient size, or use of iterative reconstruction
technique.
Findings:
There is no hydrocephalus, extra-axial fluid collection, mass, mass
effect, or herniation pattern.
There is no intracranial hemorrhage.
There is no CT evidence for acute transcortical ischemia.
Osseous structures are intact. Minimal fluid is noted in the left
mastoid air cells. The paranasal sinuses and the right mastoid air
cells are well pneumatized.
Some skin thickening and soft tissue edema are noted in the region of
the left external auditory canal, attributed to the patient’s known
otitis externa.
Impression:
No definite CT evidence of acute intracranial hemorrhage, large
territorial transcortical ischemia, mass effect, herniation or
hydrocephalus.
Soft tissue edema and skin thickening in the region of the left
external auditory canal, attributed to the patient’s known otitis
externa.
Mild left mastoiditis.
Assessment/Plan:
21 y/o female with acute otitis externa left ear with mild left mastoiditis.
Ibuprofen 600 mg PO for pain control. Per ENT recommendations Otic Ciprodex left ear twice daily for 7 days and follow up in office in 1 week.
