CC: right ear discharge x 5 days

Subjective:

68 years old female with PMHx HTN, depression, presents to the clinic for ear discharge. Patient notices odor less yellowish discharge from her right ear 5 days ago without any pain. Patient complains right ear fullness with mild itching. She states she had been experienced the same symptoms almost once per year. The last episode of ear infection happened two years ago. She cleans her ear wax once per year and the last ear wax removal was done last year. She also complains lightheadedness associated with her ear discharge. Denies recent swimming, hearing loss, tinnitus, headache, cough, SOB, N/V/D.

Objectives:

Allergies: NKDA

Current Medication:

• Amlodipine 5 mg once per day for HTN
• Zoloft 75 mg for depression

Vitals:

• BP: 126/84, sitting, left arm
• HR: 75 bpm, regular
• RR: 16 breaths per minute, regular
• O2 Sat: 97%, RA
• T: 98.6 oral
• Ht: 67 in Wt: 136 lbs     BMI: 21.3 kg/m2

Physical Exam

• Gen – Well nourished, well developed female resting in chair, no apparent distress
• HEENT – NC/AT, no JVD noted. Mild tender to palpation of the tragus. Erythematous, slightly edematous, and narrowing of the right external auditory canal with minimal yellowish discharge.
• Thorax – Symmetric, no retractions
• Lung – CTA b/l, no rhonchi, rales or wheezes noted
• CV – S1S2 distinct, no M/R/G, RRR. No carotid bruits
• Abdomen – Soft, non-tender, non-distended. Bowel sounds normoactive in all four quadrants, no masses to palp, no hepatosplenomegaly.
• Extremities –No clubbing, cyanosis, edema, radial/DP pulses +2 bilaterally
• MS – Full range of motion throughout, strength 5/5 bilaterally throughout
• Neuro – A&O x 3, no gross motor or sensory deficits, CN II-XII grossly intact

Assessment

68 years old female with PMHx HTN, depression, presents to the clinic for ear discharge. History and physical exam consistent with otitis externa.

Plan

• Rx send to pharmacy: Ciprodex (ciprofloxacin and dexamethasone) otic suspension BID x 7 days
• Swimming, use of ear plugs should be avoided until the infection is resolved.
• Return to office for re-evaluation, if the symptoms do not improve within 48 to 72 hours.