DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has been complaining of right ear pain. The patient relates that she had a similar episode approximately 4 weeks ago and saw a nurse practitioner, who diagnosed the patient with acute otitis media and treated her with antibiotics. The patient completed the course and had some improvement after 3-4 days. The patient denies any hearing loss, any problems with upper respiratory infection prior to the onset of the ear pain, and significantly, she does have allergy problems which have been exacerbated in the fall season. She has been taking Zyrtec prior to admission. She relates that she continues with nasal congestion and drippiness from her nose with associated postnasal drip, despite the fact that she is in the hospital currently. She has had difficulty with sinusitis. Importantly, she has also had problems with infected teeth and had root canals. However, denies any current or recent dental problems. She has had history of TMJ syndrome in the past. She relates that the pain is somewhat similar to this. The patient relates that she has had difficulty with cervical myalgia in the past as well as migraine headaches. She has undergone chiropractic treatment for her migraine headaches with improvement in her headache symptoms. Significantly, she has been involved in multiple accidents sustaining whiplash injuries on 4 separate occasions, according to the patient.
She recently notes that she was given a diagnosis of a nasal septal deviation as well. She denies any throat pain. She has had tonsillectomy performed in the past. She describes the pain as throbbing, achy pain. She denies any hearing loss, vertigo or otorrhea. She relates that she has had longstanding tinnitus, which she describes as a high-pitched ringing sound, worse on the right than the left, and not associated with fullness of the ear or any facial weakness. She had been previously evaluated by an otorhinolaryngologist, who performed an audiometric evaluation and found her hearing to be fine. The patient denies any significant noise exposure history. The patient denies eustachian tube dysfunction symptoms including pressure, pain, throbbing or popping sensation of the ears. She denies any acute dental problems. She denies frank symptoms of prodromal aura or migraine headaches. She denies any type of temple headache to suggest temporal arteritis. She has not had any recent trauma to the ear area. The patient denies upper respiratory infection symptoms or symptoms related to sore throat. She has no numbness or tingling sensation of the face or the head. She has discomfort related to her abdominal procedure.
CURRENT MEDICATIONS: Pepcid, Ancef, Lidoderm patch as well as a PCA, Lovenox.
PAST MEDICAL HISTORY: Morbid obesity, GERD, hypercholesterolemia, environmental allergies, peripheral edema, insomnia, chronic arthritis with associated chronic pain, history of hepatitis and TMJ syndrome. Suspect a recent history of acute otitis media.
PAST SURGICAL HISTORY: Significant for tonsillectomy, ocular procedures, appendectomy, cholecystectomy, gastric banding, bilateral podiatric procedures, tubal ligation, carpal tunnel, rotator cuff surgeries and left total knee arthroplasty.
FAMILY HISTORY: Significant for diabetes, hypertension, and coronary artery disease.
SOCIAL HISTORY: Nonsmoker. She uses alcohol on a social basis.
REVIEW OF SYSTEMS: As noted in HPI.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, blood pressure 96/56, pulse 84 and respiratory rate 21.
GENERAL: The patient is resting in her hospital bed. She appears generally to be comfortable with occasional episodes of pain. She uses her PCA frequently. The patient is in no acute respiratory distress. She is alert and oriented x3. She is conversive. There is no gross cellulitis or facial swelling noted bilaterally.
HEENT: The patient is wearing corrective lenses. Examination of the ears reveals both tympanic membranes to be intact and clear bilaterally. There is no middle ear cleft process, including effusion or infection noted. Canals and pinnae do not reveal any masses or lesions. There are no inflammatory or edematous changes. Nasal examination reveals the septum essentially in the midline anteriorly. There is a mild deflection of the septum to the left. Posteriorly, turbinates are within normal range. Both nasal passages are widely patent anteriorly. There is minimal clear discharge present. There is no significant rhinitis appreciated. The outward appearance of the nose is not markedly deviated. There are no masses, lesions or polyps noted on anterior rhinoscopy bilaterally. In the periorbital regions, there is no significant cellulitis or erythema noted. In the temple region, there is no palpable tenderness. There are no masses or lesions noted in the right parietal temporal as well as the mastoid, superior neck as well as preauricular regions, including any cellulitic changes. There is tenderness to palpation that has been initially reproduced by the patient's tenderness on the right consistent with palpation over the temporomandibular joint. Additional palpation superiorly, anteriorly and posteriorly elicited pain as well. However, did not reproduce the initial pain that the patient is complaining of. Oral examination reveals multiple areas of ulceration, gentle rasping of the upper and lower molars on the right did not elicit any tenderness. There are no inflammatory changes noted. The parotid and submandibular glands did not reveal any masses or tenderness bilaterally. Oral mucosa did not reveal any masses or lesions to the lips, hard palate and soft palate, buccal mucosa, the mouth or the tongue. The oropharynx did not reveal any localized infection, severe pharyngitis or postnasal drip, and tonsils are absent bilaterally.
NECK: Examination reveals the trachea essentially in the midline. There is no discrete thyroid mass appreciated. There is no significant cervical lymphadenopathy or masses noted. There is generalized tenderness of the paravertebral musculature as well as sternocleidomastoid notch to a much lesser degree.
LABORATORY DATA: INR 0.98, pro time 9.8, PTT 22.4. Sodium 134, potassium 4.3, glucose elevated at 198, creatinine 0.6, BUN 14, calcium 8.4, albumin 3.7, total protein 7.3, hemoglobin 11.3, white blood cell count 21.2 and platelet count 262,000.
IMPRESSION:
Right otalgia, likely secondary to referred pain from temporomandibular joint syndrome; cervical myalgia; rhinitis and deviated septum, mild; environmental allergies; obesity, status post banding; status post gastric bypass and gastric resection; respiratory insufficiency; gastroesophageal reflux disease; leukocytosis.
RECOMMENDATIONS:
The addition of NSAIDs at this time will not be entertained due to the recent surgery. The patient is currently on PCA, which should suffice. With the patient's extensive history of previous workup and evaluation and diagnoses made, we would like to check old records including audiometric evaluation and TMJ studies including Panorex x-ray or bitewings. Additional evaluation by dentistry in TMJ workup and treatment can be performed on an outpatient basis. Currently, it appears that her abdominal discomfort supersedes that of her ear. Extensive discussion including history taking and examination was completed with the patient. Questions were answered to her satisfaction but no promises or guarantees were given. The patient understands that there are additional etiologies for her otalgia and that the workup is far from being completed. However, in light of her other issues, we will defer additional workup at this time, unless her symptoms begin to accelerate. At this time, the patient's TMJ syndrome appears to be the most likely cause of her otalgia.
Tonsillectomy Sample Reports
Tonsillectomy Sample Reports
