Ahra Cho

CC: Ear infection

HPI:
Patient is a 38-year-old female, presenting to clinic today with a history of ear
infection that began on December 20th. Since then, she has been to the ER twice for an
ear infection that caused pain, itchiness, right facial swelling, ear swelling and a
concurrent eye infection that led to watery and pink eyes. Both times, she was treated
with separate rounds of antibiotics before symptoms ebbed and then came back.
She finished her last antibiotic treatment on January 26th, and while feels improved,
does not feel 100%.
This week she feels the symptoms coming back again, with a funny feeling in her
eye, and associated ear swelling and itchiness in her ear. Currently there is no associated
pain, or tingling, and no other associated ENT or systemic symptoms. Theres also no
sinus swelling, double vision, or watery eyes.
She said Ibuprofen helps with the swelling and heat and pressure makes it worse.
Even though todays symptoms are not bothering her as much, she wants antibiotics or
next steps to prevent another visit to the emergency room.
ROS was unremarkable (no fever, cough, chills, weight loss, chest pain or changes in
bowel movements)
PMH
- Hypertension that is usually well-controlled
Allergies:
- Allergic to penicillin
- No other medication allergies
Medication
- Lisinopril
- Hydrochlorothiazide
Family History
- Negative for autoimmune or nervous disorder, with no history of psorias/eczema.
Social history
- Does not smoke, drink, or use other legal or illicit drugs.
Physical Exam
- Vitals: 133/90, HR: 80, RR:20, Temperature: 37C
- Gen: Well appearing, well developed and in no acute distress
- Eyes: PERRLA, normal conjunctiva and sclera, no pinkness noted
- ENT: Nose clear without lesions or exudates. Slightly inflamed auditory meatus and
wax buildup. White scales are visible in the ear canal.
- Neck: Supple, no lymphadenopathy or masses
- CV: RRR, no m/r/g
- Lungs: CTAB, no wheezes, rales, or rhonchi
- Abd: + bowel sounds, soft, nontender, nondistended. No appreciable HSM or
masses
- Ext: no edema
- Skin: warm and dry, no lesions or rashes

Neuro: alert and oriented x 3

Psych: appropriate mood and affect

Problem List:
- Ear discomfort/itchiness
Summary:
Patient is 38-year-old woman who presents to clinic with a history of two recent
visits to the ER for a recurrent ear infection and related eye infection. She was treated
with antibiotics both times, but she currently feels a funny feeling in her eye, and
associated ear swelling and itchiness in her ear, with no associated pain, or tingling, and
no other associated ENT or systemic symptoms of fever/chills/weight loss. She has wellcontrolled Hypertension that she is treating with Lisinopril and HCTZ. Theres no family
history of autoimmune or skin disorders like psoriasis or eczema.
Physical exam shows a well-appearing woman in no acute distress. Ear exam
shows a slightly inflamed auditory meatus with white flakes along the ear canal.
Assessment and Plan:
- The recurrent infections suggest an underlying etiology. White scales seen on
physical exam suggest that she may have psoriasis or eczema in her ear that may
have caused increased her risks for infection. As the patient is undergoing a
stressful time, this may have triggered her underlying psoriasis.
- Topical antifungal or antibiotic products can treat this condition.
- She was prescribed an eardrop antibiotic with steroid in it (Ciprodex) to numb the
sensation of itchiness and allow the ear to heal.
Furthermore, she was prescribed Lidex (fluocinonide) to treat the inflammation and
itching caused by skin conditions such as allergic reactions, eczema, and psoriasis
for treatment and instructed to return if symptoms did not abate in 2 weeks.
Patient Encounter Reflection
- The patient was very friendly and spoke at succinct sentences about her condition
so it was very easy for me to take notes. It was very interesting that she chose to
come to the appointment with no acute problems. However, even though this was
a preventative visit, it was more difficult to diagnose because she didnt have
any acute symptoms.
- Furthermore, I thought the diagnosis was rather odd but in retrospect, I feel like it
makes sense that the psoriasis and the disruption of skin can cause repeat
infections, verses a resistant strain of bacteria in her ear (a theory I was leaning
toward). I like the fact that regardless of how the diagnosis went, the patient was
relieved.