EMIS Template

Specialty: Advanced Clinical Practitioner Problem: Acute Otitis Media History: Patient presents with a 3-day history of right ear pain, progressively worsening, accompanied by a muffled hearing sensation and occasional low-grade fever. States the pain is sharp and throbbing. Reports using over-the-counter paracetamol with minimal relief. Denies recent upper respiratory tract infection symptoms. The patient is a 28-year-old male with no significant past medical history. No previous surgeries. Currently taking no regular medications or herbal supplements. No known drug allergies. Social: Lives alone, works as an accountant, non-smoker, rarely consumes alcohol. Examination: Right tympanic membrane is erythematous and bulging, with loss of landmarks. Left tympanic membrane appears normal. No discharge noted in either ear canal. No mastoid tenderness. Mild right cervical lymphadenopathy. Oropharynx clear. Vital Signs: HR 78 bpm, BP 120/75 mmHg, RR 16 breaths/min, SpO2 99% on room air, Temperature 37.8°C. Comment: Imp: Acute Otitis Media, right ear. Plan of action including planned investigations, referrals and follow-up: Prescribed Amoxicillin 500mg three times daily for 7 days. Advised on pain management with paracetamol/ibuprofen. Advised to return if symptoms worsen or do not improve after 48-72 hours. Safety netting advice provided regarding fever, worsening pain, or discharge. Follow-up appointment booked for 1 November 2024 if symptoms persist.