CHIEF COMPLAINT: Wax buildup in right ear.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male with a history of cerumen impactions of the right ear, who presented to the ER with complaints of buildup of wax in his right ear for the last week. He also reports decreased hearing to the point where he is able to hear approximately 20%. He has tried mineral oil as well as peroxide and irrigations with bulb syringe with no relief at home. He has required ENT followup in the past when he was in (XX); however, he does not have a primary care physician here. He denies any pain associated with this. He does feel slightly off balance and almost had an accident on his bicycle today; he believes due to the wax buildup. He, otherwise, has no complaints.
PAST MEDICAL HISTORY: Tonsillectomy.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Not elicited.
SOCIAL HISTORY: The patient is a nonsmoker and does not have a primary care physician.
REVIEW OF SYSTEMS: As stated above, in the HPI, significant for wax buildup in the right ear associated with some lightheadedness and decreased hearing. He has, otherwise, been well without fevers, chills, nausea, vomiting, URI symptoms, polyuria, polydipsia, heat or cold intolerance, fatigue or recent weight changes. Further review is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/92, pulse 88, respirations 18, temperature 97.8, and pulse ox on room air is 100%
GENERAL: This is a well-developed, well-nourished Hispanic male in no acute distress. He is alert and oriented x3.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. The left ear canal has a moderate amount of cerumen. The TM can be visualized. There is no erythema, bulging or retraction noted here. The right TM is completely obscured by cerumen; although, it does appear soft, not a complete impaction in the canal. There is no tenderness with palpation to the tragus, pinna or with percussion to the mastoid process. Oropharynx exhibits no erythema or exudate.
NECK: Supple without lymphadenopathy.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Warm, dry, and intact.
EMERGENCY DEPARTMENT COURSE: The patient’s ear was irrigated using a 50:50 solution of hydrogen peroxide and warm water with good results. A significant amount of cerumen was flushed out of the ear canal. The TM could then be visualized. There was no evidence of infection or rupture. The patient reported significant improvement in his symptoms, including complete resolution of his hearing loss.
DIAGNOSIS: Right cerumen impaction, resolved.
PLAN:
1. The patient is to follow up with his local clinic of choice and was also given the number for ENT physician on-call for further followup of problems.
2. He is to take Advil or Motrin as needed for pain.
3. Return to the ER for any worsening symptoms.
DISPOSITION: The patient was discharged to home in good condition and ambulated out of the department without difficulty.
