Initial considerations in
this patient included acute otitis media, otitis externa, mastoiditis, ear
foreign body, tympanic membrane
rupture, pneumonia, and other upper respiratory infections (URI) among others.
Patient presented with
complaint of [fever/fussiness/ear pain] and was noted to have evidence of
erythema, [bulging,] and effusion on examination of the [right/left] tympanic
membrane consistent with otitis media.
[Visualization of the tympanic membrane incomplete due to cerumen in the
external auditory canal, but no evidence of significant erythema or bulging of
the visualized portion.] Patient noted
to have associated fever, ear pain, and [upper respiratory symptoms] consistent
with otitis media. No abnormal lung
sounds, sputum production, [abnormal findings on chest x-ray,] or other
findings suggestive of pneumonia noted. No
evidence of debris or swelling of the external auditory canal suggestive of
otitis externa noted on exam. No
evidence of perforation of the tympanic membrane noted on exam.
We discussed [watch and wait
prescription of antibiotics/discharge with antibiotics] with the patient’s
[mother/father/parents] who demonstrated understanding and agreement with this
plan. Prior to
discharge, we discussed return precautions, specifically for evidence of
worsening infection, and follow up with primary care doctor within [2-3 days/1
week] for further evaluation, and the patient’s [mother/father/parents]
demonstrated understanding and agreement with this plan.
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