H&P

Chief Complaint: “Left ear pain” x 3 days

History of Present Illness:

36 y/o male patient with past medical history of hypertension presents to the family medicine clinic for left ear pain x 3 days. Patient states the severity of the pain is a 7/10 and has muffled hearing out of that ear as well. He states that he has been using Q-tips for a long time and last used them last week. He admits to trying ibuprofen 400 mg to try and alleviate it but with minimal relief. Patient denies history of ear infections in the past. Patient also denies fever, discharge from his ear, tinnitus, sinus pressure, headache, nuchal rigidity, cough, nasal congestion, sick contacts, recent swimming, or nausea/vomiting.

Patient also admits to not taking his blood pressure medication (Amlodipine) for the past 3 months because he wanted to “take a break from it”. Patient states that he wanted to see how his blood pressure was without any medication before beginning it again. He says that he has felt asymptomatic during this time while he wasn’t taking the medication and felt that he didn’t need the medication anymore. Patient denies keeping a log of his blood pressure readings at home. Denies any headache, blurry vision, dizziness, chest pain, or SOB. 

 Past Medical History:

  • Hypertension

Past Surgical History:

  • No past surgical history

Medications:

  • Amlodipine 10 mg once a day 

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • Mother: Age 60, alive and well, PMHx DM 2
  • Father: Age 66, alive and well, hypertension
  • Maternal grandmother: unknown
  • Paternal grandparents: unknown

Social History:

  • Smoking: non-smoker
  • Substance use: Reports social alcohol use. Denies drug use
  • Caffeine: Admits to caffeine use, 1 cup of coffee per day
  • Occupational history: Elementary school teacher
  • Home situation: lives in apartment with his wife

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies head trauma, vertigo.
  • Eyes: Denies contacts/glasses use, visual disturbances, eyelid swelling, pruritus, photophobia, lacrimation. 
  • Ears: Admits to left ear pain and muffled hearing in left ear. Denies discharge or tinnitus.
  • Nose: Denies nasal congestion, epistaxis, or discharge.
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, hx of HTN, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Denies change in appetite, intolerance to specific foods, abdominal pain nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Sexual History: Admits to currently being sexually active with wife only. Admits to condom use. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional. 

Physical Exam:

Vitals:

  • BP: 138/86 (seated, left arm)
  • HR: 72 BPM (regular)
  • RR: 16/min (unlabored)
  • T: 97.1 F (oral)
  • O2: 100% (room air)
  • Height: 69in Weight: 156lbs BMI: 23.0

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Eyes: PERRLA. EOM intact, no nystagmus. Sclera white, cornea clear, conjunctiva pink.

Ears: Left ear: Canal intact, no swelling or erythema. Mild amount of cerumen noted in canal. TM erythematous and bulging.  No discharge or foreign bodies noted. Auricle in good position. No mastoid tenderness. No tenderness of the tragus.

Right ear: TM pearly grey and intact with light reflect in good position. No tenderness, discharge or foreign bodies.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink.

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Bowel sounds normoactive. Nontender, no guarding or rebound noted.  

Differential Diagnosis:

  1. Acute otitis media – Most likely due to physical exam showing erythematous and bulging TM
  2. Acute otitis externa – Not as likely as AOM as the physical exam is not painful and TM is visualized as bulging and there is no discharge in the ear canal.
  3. Cerumen impaction – There is some cerumen in left ear but less likely to be causing the symptoms. 
  4. Mastoiditis – Included in differential as it is a complication of AOM. Since there is no mastoid tenderness this diagnosis is unlikely.
  5. Sinusitis – Less likely due to non-tender sinuses. 

Assessment:

36 y/o male patient with PMH of hypertension complaining left ear pain x 3 days. On exam, the patient is afebrile and there is erythema and bulging of the right TM noted. The auricle is nondisplaced and there are no signs of effusion or perforation. Symptoms and signs are consistent with acute otitis media. Pt also has not been taking his blood pressure medication x 3 months and has a blood pressure of 138/86 today. 

Diagnosis: Acute otitis media

Plan for AOM: 

  1. Start amoxicillin 875mg-clavulante 125mg (Augmentin) BID x 10 days
  2. Pain relief – use OTC Ibuprofen or Tylenol PRN
  3. Ear hygiene: Avoid using Q-tips. Clean ears gently in shower with damp washcloth. For built up earwax use over the counter debrox ear drops. 
  4. Follow up if: severe ear pain, pus or blood draining from ear

Plan for Hypertension: 

  1. Start Amlodipine 5 mg once a day. 
  2. Emphasized importance of adherence to treatment and complications of uncontrolled hypertension. 
  3. Keep a log of blood pressure readings at home and bring during next follow-up. 
  4. Lifestyle Changes: Regular Exercise (3-4 times a week of 30 minutes each) and well-balanced diet.

Family Medicine H&P