S- Subjective Data:
K. M; 8 y/o African American female
History obtained from mother of patient.
Established patient in office; last well visit in August 2014.
Chief Complaint (CC): “My left ear hurts”
History of Present Illness (HPI): K. M. presents to clinic accompanied by his mother with a complaint of
left ear pain for 3 days. Rates pain as 6/10 on scale 1-10, describes as constant and throbbing. Mother
states pain began while K. M. was sleeping and has progressively worsened. Mother states she has been
alternating Tylenol and Advil which alleviates the pain. K. M. denies any aggravating factors. Denies any
other symptoms such as fever, cough, nasal congestion, or sore throat.
Past Medical History:
Medications:
Singulair 5 mg PO daily at bedtime
Children’s Tylenol 3 teaspoons PO q 4 hours PRN pain/fever
Children’s Advil 3 teaspoons PO q 6 hours PRN pain/fever
Mother denies problems/side effects with medications. Mother states K. M. takes his medications as
prescribed on a daily basis.
Allergies: NKDA
Prior Illnesses/Injuries:
Allergic rhinitis
Previous Injuries: none
Previous Operations: none
Previous Hospitalizations: none
Childhood immunizations- UTD
Flu vaccine: October 2014
Family History:
Mother- Age 28; no medical problems
Father- Age 32; no medical problems
Brother- Age 6; Asthma x 2 years
Maternal grandmother- Age 49; Asthma
Social History: Patient lives with both parents and brother, age 6; four members of household. Patient is
a third grader at Oxford Elementary School in Oxford, Alabama. Patient rides the bus to and from school.
Patient and his family lives in a single-story house in a subdivision approximately two miles from the
school. Patient wears his seatbelt on a regular basis. Patient is involved in extracurricular activities,
including football and baseball. Mother denies patient being exposed to second-hand smoke. Patient
denies use of tobacco, alcohol, or drugs. No pets in home.
Nutrition: Pt eats a well-balanced diet. Mother states patient eats cereal and toast with orange juice in
the morning, eats a school-provided lunch at lunchtime, and dinner at home with family. Mother states
the family eats fast food approximately twice a week. Patient consumes two snacks during the day, one
at school and one after school, usually fruit or a granola bar.
Review of Symptoms:
1. Constitutional: Patient denies fatigue or weakness, recent weight loss or gain, denies fever.
2. Eyes: Denies vision changes, blurry vision, eye drainage/tearing, eye pain/itching or eye redness.
Denies photophobia. Last eye exam- August 2014 with no abnormal findings. Visual acuity at eye exam
was 20/20 OU.
3. ENMT: Patient denies vertigo or tinnitus. Complains of left ear pain x 3 days. Denies ear drainage.
Denies nasal discharge or nosebleeds. Denies difficulty smelling. Pt denies facial/sinus pain or sinus
drainage. Denies bleeding of gums, mouth odor, ulcers, or sores of the tongue.
Denies sore throat, hoarseness, or difficulty swallowing.
4. Cardiovascular: Patient denies chest pain, palpitations, dyspnea, orthopnea, or peripheral edema.
Denies cyanosis of extremities. Denies leg redness or tenderness. Mother of patient denies history of
heart murmur, varicose veins, claudication, or history of DVT.
5. Respiratory: Patient denies SOB at rest or upon exertion, orthopnea, or dyspnea. Denies wheezing,
hemoptysis, or night sweats. Denies cough or sputum. Denies history of pneumonia, RSV, bronchitis, or
asthma.
6. Gastrointestinal: Denies any episodes of abdominal pain, nausea, vomiting, or diarrhea. Reports
regular, daily BM’s. Last normal BM was today. Denies blood in stool, rectal bleeding, or constipation.
Denies hematemesis. Denies heartburn. Reports normal appetite with no food intolerances.
7. Genitourinary: Patient denies dysuria, burning, urgency, hematuria, or frequency. Denies flank pain or
suprapubic pain. Denies recent urinary tract or bladder infections. Patient is not sexually active.
8. Musculoskeletal: Patient denies body aches, muscle pain, swelling, or stiffness. Denies recent injury
or trauma. Denies muscle cramps or muscle weakness. Patient is physically active on a daily basis.
Denies neck pain or stiffness. Denies changes in range of motion of upper and lower extremities.
9. Skin: Denies skin lesions, rash, itching, moles, hair loss, or dryness. Reports sun exposure
approximately six times weekly. Uses sunscreen on a regular basis.
10. Neurologic: Patient denies headaches, dizziness, or vertigo. Denies syncopal episodes, fatigue, or
weakness. Denies muscle tremors, numbness, involuntary movements, or tingling. Denies sleep
disturbances.
11. Psychiatric: Patient denies recent mood changes. Denies history of depression and anxiety,
hallucinations or paranoia.
12. Endocrine: Denies intolerance to heat or cold, excessive sweating, thirst, or hunger. Denies any
unexplained changes in weight. Denies changes to skin.
13. Hematologic/Lymphatic: Denies excessive bleeding, bruising, or history of anemia. Denies any
previous blood transfusions. Denies swollen lymph nodes or lymph node tenderness. Denies previous
history of blood clots.
15. Allergic/Immunologic: Reports perennial allergic rhinitis. Denies previous allergy testing. Denies
hives, rashes, or itchy, watery eyes. No exposure to blood or body fluids. Denies history of
immunosuppression. Denies lead exposure.
O- Objective Data:
1. Constitutional/General appearance: 8 year old well developed, well-nourished male appearing to be
in a good state of health. Patient appears in no acute distress. Dressed appropriately and behaving in an
appropriate manner. Alert and oriented x 3. Answers all questions appropriately.
Vital Signs: T- 98.7 oral, BP- 112/68 mm/Hg, HR-90 bpm, Respirations- 20/ minute, unlabored, Oxygen
sat- 100% on room air, Height- 48 inches, Weight- 68 lbs, BMI- 20.8. Patient is in 90th percentile in height
on pediatric growth chart, and in 90th percentile in weight on pediatric growth chart.
Physical Examination:
2. Eyes: Sclera normal. No drainage or tearing noted from eyes, no redness. PERRLA. 3 mm bilaterally.
3. ENT/Mouth: Left and right ear canals visualized and normal. Cerumen present in both ear canals.
Right tympanic membrane dull, gray, normal landmarks visualized; no bulging or redness noted, light
reflex present. Left tympanic membrane bright red and bulging; light reflex present. Hearing intact to
whispered voice. Nasal turbinates normal. No redness, paleness, or bogginess noted to nasal mucosa.
No nasal drainage noted, no deviated septum, no lesions noted. Maxillary and frontal sinuses nontender
upon light or deep palpation. Oral cavity mucosa pink and moist. Pharynx reddened with no exudate
visualized, tonsils present and normal, uvula midline. No evidence of bleeding of gums or foul odor, no
ulcers or sores.
Cardiovascular: Apical pulse normal. Regular rate and rhythm noted. Normal S1 and S2. No S3 or S4. No
murmurs, clicks, or gallops. Peripheral pulses with normal rate and rhythm. No JVD. No carotid bruits
auscultated. No edema noted to upper or lower extremities. Capillary refill brisk, < 3 seconds. No
discoloration noted to extremities.
Respiratory: Equal rise and fall of chest visualized. No tenderness upon palpation. Patient with normal
rate and effort. Normal tactile fremitus. No hyperresonnance or dullness noted upon palpation. Normal
breath sounds auscultated in upper and lower lobes bilaterally. No rhonchi or wheezing auscultated.
Abdomen: Abdomen soft and nondistended. Bowel sounds normal in all four quadrants. No tenderness
noted upon light or deep palpation. No guarding.
Genitourinary: No CVA tenderness present.
Musculoskeletal: Normal ROM noted in upper and lower extremities. Denies calf tenderness. Normal
muscle strength in upper and lower extremities. No abnormal curvature of spine. No warmth or edema
noted to joints.
Skin: Skin warm, dry, pink. No bruising noted. No discolored or uneven moles, open wounds, no redness
or rashes noted. Hair on arms and legs evenly distributed.
Neurological: Patient is alert and oriented x 3. Hand grips strong and equal bilaterally. Speech is clear.
No tremors or involuntary movements.
Psychiatric: Pt is calm, cooperative, behaving in an appropriate manner, answering questions
appropriately. Normal affect.
Hematologic/Lymphatic/Immunologic: No bruising noted. No enlarged lymph nodes palpated. Patient
denies tenderness upon palpation of thyroid.
Results of Diagnostic Tests:
No diagnostic tests performed in office at time of visit.
A- Assessment/Analysis:
Level of Visit: Level 3- Visit Code 99213
Diagnoses:
1. 382.00 Otitis Media, acute; left ear
P- Plan:
1. New Rx for Amoxicillin 250 mg/5 ml, take 7 ml PO BID x 10 days, dispense 150 ml with no refills;
product selection permitted.
1. New Rx for Auralgan Otic Solution (Benzocaine/Antipyrine), Fill ear canal with 2-4 gtts of solution,
moisten cotton pledget with Auralgan, and insert into ear TID PRN ear pain, dispense one bottle with
no refills; product selection permitted.
1. Continue Tylenol and Advil for ear pain.
1. Start antibiotics immediately. If no improvement in 2-3 days after starting antibiotics, return to
clinic for follow- up. If symptoms resolved with antibiotic therapy, return to clinic for a follow-up in
two weeks.
1. Patient is instructed to take all medication as prescribed and in their entirety. Medication education
provided for patient/mother at time of discharge from clinic.
Amoxicillin 250 mg/5 ml- available in generic. Brand name, Amoxil, no longer available.
Indication for this patient: Amoxicillin- prescribed for treatment of otitis media.
MOA- Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death
and resultant bactericidal activity against susceptible bacteria.
Usual dosage- for mild to moderate infections, > 3 months and < 40 kg: 25 mg/kg/day PO divided q12
hours or 20 mg/kg/day PO divided q8 hours.
Prices for medication:
Publix Oxford, AL- Brand: No longer available at pharmacy, Generic: Free
CVS, Anniston, AL- Brand: No longer available at pharmacy, Generic: $9.68
Target, Anniston, AL= Brand: No longer available at pharmacy, Generic: $4.00