CHIEF COMPLAINT: Earache.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female was at the beach today. She was knocked down by a wave, and dad thinks she got water in her ear. She is complaining of left earache. There is no recent upper respiratory infection, nasal congestion, rhinorrhea, sore throat or cough. The patient presents awake and alert, in no obvious physical distress.
PAST MEDICAL HISTORY: Positive for asthma.
MEDICATIONS: Pulmicort and albuterol.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As noted above in HPI. Remainder of review of systems essentially negative.
IMMUNIZATION: Up-to-date.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed, well-nourished (XX)-year-old female, awake and alert, in no acute physical distress.
VITAL SIGNS: Temperature 98.4, pulse 110, respirations 20, and O2 saturation on room air 99%, which is excellent. Weight is 15 kilograms.
HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles intact. Nares patent. Right EAC and right TM shiny and clear. Left EAC with erythema and edema. Left TM is poorly visualized, but appears intact. Oral mucosa moist.
NECK: Supple. No nuchal rigidity or cervical lymphadenopathy noted.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft.
EXTREMITIES: Normal x4.
NEUROLOGIC: Grossly nonfocal.
SKIN: Warm and dry.
DIAGNOSIS: Left otitis externa.
PLAN:
1. The patient is discharged home on Auralgan 2 drops left ear q.i.d. p.r.n. pain, Cortisporin Otic solution 2 drops left ear q.i.d. x7 days.
2. She is to follow up with Dr. John Doe and return to the emergency department as needed.
DISPOSITION: Discharged.
Sample #2
CHIEF COMPLAINT: Earache.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old, otherwise healthy male who presents to the emergency department with his father, who states that he has had a earache for the last 5 days. He has had no fever, chills, runny nose, cough or sputum production. He has had no chest pain or cough, and he has no sinus or facial pain. He has no nausea, vomiting or vertigo. No changes in his hearing, and he does not surf or go into the ocean very much. He states he has otitis media about twice a year.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative fever or chills.
HEENT: Eyes: Negative visual field deficit or double vision. ENT: Negative sore throat or runny nose.
PULMONARY: Negative shortness of breath, cough, sputum production.
CARDIOVASCULAR: Negative chest pain on exertion or palpitations.
GASTROINTESTINAL: Negative nausea, vomiting, diarrhea, abdominal pain.
GENITOURINARY: Negative frequency, urgency or dysuria.
ENDOCRINE: Negative polyuria or polydipsia.
HEMATOLOGIC: No unusual infections or bleeding.
NEUROLOGICAL: No headache or confusion.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a well-developed, well-nourished, well-appearing male, in no acute distress.
VITAL SIGNS: Blood pressure 112/66, heart rate 74, respiratory rate 18, pulse oximetry 99%, temperature 98.4.
HEENT: NC/AT. PERRLA. EOMI. Sclerae normal. Conjunctivae normal. Nares: Dried green rhinorrhea. Mucosa is boggy. Pharynx: Anterior tonsillar pillars are markedly red. Tonsils are normal. There is no exudate. The uvula is midline. The floor of his mouth is nontender. Sinuses are nontender to percussion. TMs: Normal. Canals: Normal. No traction on the pinna.
NECK: C-spine: Supple. There is some shotty, nontender, anterior cervical lymphadenopathy. No supraclavicular lymphadenopathy and no periauricular lymphadenopathy. Otherwise, there is no tenderness.
THORAX: Nontender.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm without murmurs, gallops or rubs.
ABDOMEN: Soft and nontender without hepatosplenomegaly and without pulsatile mass.
EXTREMITIES: Pulse is 2+ and equal throughout without CCE.
NEUROLOGIC: Awake, alert, articulate and oriented x3. Cranial nerves II through XII intact. Motor and sensory equal and intact.
SKIN: Normal. No rash.
DIAGNOSIS: Otalgia.
PLAN:
1. Follow up with Dr. John Doe in a week.
2. Return if headache, nausea, vomiting, fever, chills, increased pain or severe symptoms.
DISPOSITION: Discharged.
