Medical Record Documentation of Otitis Media
Name: William Cray1
Date of birth: August 3, 19872
Drug allergies: None known3
Immunizations: "Up to date" according to mother4
Thursday, December 12, 1991 Emergency Department
CHIEF COMPLAINT: "Fever and earache."
HISTORY: Stuffy nose and cough for a week. Seemed to be getting better, but started crying with ear pain this afternoon. Pain has continued and he feels warm to mother.
"Lots of ear infections" (old chart not available). Followed in clinic; regular examination "last spring." Most ear infections treated in emergency department. No other long-term problems; no serious illnesses, hospitalization. No known drug allergies. Mother says he has had all his shots.
PHYSICAL EXAMINATION: Quiet, alert black boy; cries on examination but is cooperative.
Weight: 41 lbs.
Temperature: 38.8°C, rectal.
Skin: Clear.
Eyes: Clear.
Ears: Left tympanic membrane dull, gray, normal landmarks. Right tympanic membrane bright red and bulging.
Nose: Swollen, red membranes with opaque white mucus.
Throat: Clear.
Neck: Supple; numerous small lymph nodes.
Chest: Breathing easily; clear.
Heart: Good sounds in regular rhythm without murmurs.
Abdomen: Soft; no tenderness or masses.
IMPRESSION:
1. Acute otitis media, right.
2. Recurrent otitis media by history.
3. Need for continuity.
PLAN:
1. Amoxicillin, 250 mg t.i.d. for 10 days.
2. Acetaminophen 240 mg every 4 h for pain.
3. Follow-up in clinic, 3 wks; review old record then.
Sandra Schultz, MD, PL-1
Friday, January 3, 1992 Pediatric Clinic
CHIEF COMPLAINT: "To check his ears."
