DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Blood from the left ear.
HISTORY OF PRESENT ILLNESS: The patient states that he woke up this morning with left ear pain. Later in the day, he put his finger in his left ear, and it started to bleed. He did have tubes placed in his ear about a year ago. Immunizations are up-to-date. The patient denies any headache, right ear pain, rhinorrhea, sore throat, neck pain or stiffness, cough, abdominal pain, nausea, vomiting, diarrhea, fever or any other complaints.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY:
1. PE tubes.
2. Adenoids removed.
MEDICATIONS: Advil.
ALLERGIES: None.
REVIEW OF SYSTEMS: See HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 104/66, temperature 97.2, pulse 92, respirations 20, and pulse ox is 97% on room air.
GENERAL: This is a (XX)-year-old Hispanic male in no acute distress, alert and oriented x3, pleasant and cooperative throughout the exam.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular movements are intact. The right TM is benign. There is a blue tube still in position. The left tube is difficult to see, if it is still in the ear, because there is a large amount of blood, wax and what appears to be serous fluid wrapped around, possibly the tube. The superior portion of the TM is visualized, and it looks normal. Nares are patent bilaterally. Oropharynx is benign.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
EMERGENCY DEPARTMENT COURSE: Dr. John Doe examined and evaluated the patient and explained that we would put him on an oral antibiotic.
DIAGNOSIS: Acute left otitis media.
PLAN:
1. Amoxil.
2. Tylenol or ibuprofen p.r.n.
3. Off school Tuesday.
4. Follow up with ENT or primary care physician.
5. No water, Q-tips or fingers in the ear.
6. Return if problems.
DISPOSITION: The patient was treated and released in stable condition.
