CHIEF COMPLAINT: Left ear pressure.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who complains of left ear pressure for the last three months. The patient states that she felt that it may be wax buildup and therefore used some over-the-counter ear wax drops but only used these on two occasions. She stated it did not relieve her symptoms.
The patient denies any drainage from the ear. She denies any fevers or chills. She has not seen her doctor regarding this. In addition, the patient has had a past history of hypertension and states she has been out of her medications for approximately the last four months. She denies any headache, dizziness, blurred vision, chest pain or shortness of breath.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS: The patient was taking Caduet but has been out for four months.
ALLERGIES: Penicillin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies tobacco, drinks alcohol occasionally, and uses marijuana.
REVIEW OF SYSTEMS: As above. Otherwise, negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 182/110, pulse 84, respirations 14, and temperature 99.2.
GENERAL: The patient is a well-developed, well-nourished female in no acute distress.
HEENT: Normocephalic and atraumatic. PERRLA. EOMI. Right TM is intact with good light reflex. There is no obstruction in the external auditory canal. The left ear shows that the external auditory canal is occluded with cerumen. It does appear that the cerumen is very compacted down to the level of the TM. The TM is not visible. There is no erythema or edema noted to the external auditory canal. There is no tenderness with palpation of the pinna or tragus. Posterior oropharynx is pink and moist without erythema or exudate.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
EMERGENCY DEPARTMENT COURSE: The patient’s nursing notes were reviewed. The patient did have a recheck of her blood pressure, which was 192/114. The patient remained asymptomatic.
MEDICAL DECISION MAKING: The patient does appear to have a cerumen impaction in the left ear. We will encourage her to use over-the-counter ear wax drops for a longer period of time, and if she does not have any resolution of her symptoms in the next 10 days, she is to call the ENT clinic for followup.
The patient also has a history of hypertension and has been out of her medications for the last four months. We will refill her Caduet and encourage her to follow up with her primary care physician regarding her elevated blood pressure. She is currently asymptomatic and therefore we do feel the patient can be safely discharged and encouraged to take her medications today.
DIAGNOSES:
1. Cerumen impaction.
2. Hypertension.
PLAN:
1. The patient is given a refill of her Caduet.
2. She is to use the over-the-counter ear wax drops on a regular basis for the next 10 days. If she has no improvement, she is to call the ENT clinic.
3. Follow up with her doctor regarding her elevated blood pressure.
4. Return to the ER for any concerns.
DISPOSITION: The patient was discharged home in good condition.
