DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Right earache.
HISTORY OF PRESENT ILLNESS: The patient has had congestion, coryza, and cough for about a week and a half. About a day and a half ago, she had a right earache that was followed very quickly by a rupture and relief of most of the pain. She has had this in the past, the most recent being two months ago where she was treated with amoxicillin. She refused ear drops at that time. She is not complaining of any fever, headache, sore throat, chest pain, dyspnea, wheezing, stomachache, nausea, vomiting, or diarrhea.
PHYSICAL EXAMINATION: Temperature is 98.2 degrees orally. Blood pressure is 116/68. Weight is 170 pounds. In general, the patient looks well and in no acute discomfort. The right tympanic membrane was covered in a thick purulent material with granulation and a lot of redness. The left tympanic membrane was normal. She had a clear nasal discharge with reddish mucosa. Oropharynx revealed no redness, exudate, or swelling. There was no neck adenopathy. Lungs were clear to auscultation with good breath sounds. There were no rales, rhonchi, or wheezes. Abdominal exam was normal.
ASSESSMENT:
1. Right otitis media, status post rupture.
2. Upper respiratory tract infection.
PLAN:
1. Amoxicillin 500 mg p.o. t.i.d. for 10 days.
2. We also advised her to use ear drops, but she refused. She will think about it and get back to us if she is interested.
3. Symptomatic treatment of the cold.
4. Year check in two weeks.
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient was seen today because of sinus congestion, right ear pain. He had taken amoxicillin with initial sinus symptoms, but symptoms have progressed with cough and congestion without wheeze. No known antibiotic allergy. Past records reviewed and note of possible chondrocalcinosis on a knee x-ray in the remote past. Energy level has been sluggish this month as he has felt ill. TSH has been mildly elevated, but he has declined thyroid medication treatment.
OBJECTIVE: On examination, right tympanic membrane is slightly red, retracted. He is not able to equalize pressure. Turbinate hypertrophy, partial nasal obstruction, right greater than left nostril. Posterior pharynx appears normal. No thyroid enlargement or nodule. Lungs are clear. Regular rhythm.
ASSESSMENT AND PLAN:
1. Sinusitis and right otitis media: Therefore, azithromycin 500 mg a day for five days. He may need to repeat the five-day course.
2. Hypothyroid: Repeat TSH pending, without medications at this time.
3. Joint pain, possible chondrocalcinosis: Vitamin D level is pending. He has a followup scheduled and will call if other than steady improvement with above treatment.
