Chief Complaint: “Ear pain ”x 2 days

History of Present Illness:

  7 y/o BIB mother after noticing persistent ear pain in the right ear for 2 days. Patient states the pain began suddenly and remains constant, rated 5/10. He also reports decreased hearing in the affected ear. Mother states due to ear pain, he did not attend school today and states she constantly sees him pulling on his ear to relieve pain. Mother states at home her son has had a mild fever(100.4) since yesterday. Mother states giving tylenol for both ear pain and fever with mild relief. Patient denies recently being sick, but states his nose is a bit runny. Patient denies any trauma to the ear or recent water exposure.Patient denies any recent travel or contact with sick individuals.Denies any cough, sore throat, allergies or history of ear infections.

Medications:

None

Medical history:

Denies

Surgical History:

None

Immunization Hx:

Per CIR Database: All immunizations up to date

Allergies:

NKDA,No known food or environmental allergies

Family History:

Father: Alive 38 yrs, no known medical history 

Mother: Alive 36 yrs, no known medical history 

Social History:

D.V is a 7 y/o boy who lives in an apartment with his parents in Jamaica,Queens.

Diet: Regular diet with balanced intake of vegetables and proteins

Sleep: 9-10 hours of sleep daily

Exercise:Plays soccer at school.

Travel: Denies recent travel

Review of Systems:

General: Reports to a fever of 100.4 at home. Denies chills, fatigue, loss of appetite.

Skin, hair, nails: Denies changes in texture, discolorations, rashes, or pruritus.

Head: Denies headache, head trauma, dizziness.

Eyes: Denies swelling, pruritus, warmth, and erythema. 

Ears: Reports right ear pain and decreased hearing. Denies discharge or hearing loss in the left ear.

Nose/sinuses: Reports runny nose.Denies epistaxis or obstruction.

Mouth/throat: Denies bleeding gums, mouth ulcerations, sore throat, voice changes.

Neck: Denies swelling or decreased range of motion.

Pulmonary System: Denies shortness of breath, cough, wheezing.

Cardiovascular System: Denies chest pain or palpitations.

Gastrointestinal System: Denies nausea, vomiting, abdominal pain, diarrhea.

Genitourinary: Denies urinary frequency, urgency, dysuria.

Musculoskeletal System: Denies deformity, swelling, pain.

Hematological System: Denies easy bruising or bleeding.

Nervous System: Denies sensory disturbances, weakness, 

Physical:

General: 7 y/o healthy male appears as his stated age, in mild distress due to ear pain, dressed appropriately for the weather and A&O x3.

Vitals:

Temperature: 100.8 F

Height: 50 inch

Weight: 60 lb

BMI: 16.9 /74%

Respiratory Rate: 18

BP:Not taken

PHYSICAL EXAM

Skin: No masses, scarring or bruising noted. Skin warm and nonicteric.

Hair: Average quantity. No lice or seborrhea noted.

Nails: No spooning or clubbing of nails.

Head: Head normocephalic, atraumatic.

Eyes: Symmetrical OU. Sclera white. Conjunctiva pink. 

Ears:Symmetrical,no masses,discharge or foreign bodies noted in the external auditory canals,  Right TM bulging and erythematous. Left tympanic membrane pearly gray, intact with no effusion.   

Nose: Nares patent bilaterally. Clear rhinorrhea noted 

Mouth/Pharynx: Lips pink and moist with no cyanosis or lesions. Buccal mucosa pink and well hydrated. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema present. Uvula midline. Tonsils present with no exudates.

Neck/Thyroid:The trachea is midline without masses or scars. No anterior cervical lymphadenopathy on palpation.  

Cardiac:Regular rate and rhythm, S1 and S2 present on auscultation. No murmurs, gallops, rubs, S3, or S4.

Lungs: Clear to auscultation bilaterally, no adventitious sounds noted.

Abdomen: Abdomen flat and symmetric, non-distended, no masses, ecchymosis or striae noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted. 

Musculoskeletal: No soft tissue swelling. FROM in upper and lower extremities.

Assessment:

7 y/o male, with no PMHx presents to outpatient pediatric clinic for right ear pain for 2 days. Physical exam showed a bulging and erythematous TM suggestive of acute otitis media.

DDx:

Acute Otitis media 

Otitis Externa

Eustachian Tube dysfunction 

Foreign Body

Plan:  

#Acute Otitis Media

• Start Amoxicillin 500 mg/5 Ml suspension:
  • Dosage 12  mL every 12 hours for 10 days.
• Continue to take Acetaminophen PRN for pain and fever control
• Follow up in 2 weeks for reevaluation or sooner if symptoms worsen.