Chapter 6: Special Sensory Organs: Eye and Ear | Juan Rodriguez's Chart Note

CHART NOTE

Patient Name: Rodriguez, Juan
ID Number: JR4239
Examination Date: February 6, 20xx

SUBJECTIVE
This 4-year-old male patient was brought in by his mother, who states he had a cold last week. He woke up this morning screaming, felt hot, and was tugging on his left ear. This is the third episode this year. Mother concerned with potential hearing loss.

OBJECTIVE
Temperature is 102.5° F and pulse is 100. Left tympanic membrane is dull, red, and bulging. Eyes are clear. Nose and throat clear. Neck is supple without adenopathy (disease of gland tissue). Lungs are clear.

ASSESSMENT
Left acute otitis media.

PLAN
Augmentin® (penicillin) 250 mg t.i.d. (three times a day) x 10 days. Recheck at end of treatment. Due to her concern with a hearing loss, I discussed a tympanometry evaluation and/or referral to an otorhinolaryngologist (ENT), an ear, nose, and throat specialist.