COURSE:

NGR 6002C: Advanced Health Assessment and Diagnostic

Verify Pt Name:

CC:“I have left earache.

I have an uncomfortable feeling of fullness in that ear and it feels like it’s clogged.” HPI: Left earache started two days ago inside the ear and has been there for two days. Patient admits to going scuba diving in Key West last weekend, and then one week later is when she started feeling this fullness inside her ear. Inside the left ear, it feels full, clogged, achy, uncomfortable (no pain) and this feeling is constantly there. Patient constantly hearing muffling sounds, and nothing has made it feel better or worse. Patient tried over the counter Afrin spray once a day for two days, but it did not help. The fullness inside the ear and muffling sounds have gradually gotten worse to the point where the patient can’t hear on that ear. Medications:Patient does not take prescription medications, supplements/herbs, or Cannabis. Patient tried over the counter Afrin spray once a day for two days for the earache but is not currently taking it. Currently, patient does not take any OTC medications. Allergies:Patient denies any allergies to OTC medications, food, environmental, or latex.Patient admits to being allergic to Penicillin. When asked what type of reaction she gets, she stated “she gets a rash.” Patient has no other allergies to prescription medications. PMH:Patient does not have diabetes, any heart, lung, liver, kidney, or ear problems. Patient does not have history of allergies, atopic dermatitis, or asthma. PSH:Patient had T & A removed at six years of age. Patient did not have a D&C, did not have her appendix removed, and denies any other types of surgeries. PFH:Both maternal and paternal grandparents are alive and have diabetes. Both her parents, one brother, and one sister are alive and do not have diabetes, any heart, lung, liver, kidney, or ear problems. Patient denies family history of allergies, atopic dermatitis, or asthma. Patient has one daughter with no diabetes, any heart, lung, liver, kidney, or ear problems. Social History: -Tobacco: Patient does not use tobacco/e-cigarette. -Alcohol: Patient does not drink any wine, hard liquor, beer, or any other type of alcohol. -Illicit substances: Patient denies illicit/recreational substance use. -Social support system: Patient admits to having a good relationship with her husband and best friend who live locally.

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