Patient Demographics
Identification (ID)- Patient Initials: M.X.
Date of Birth: XX/XX/XXXX
Age: 27-years-old
Sex/Gender: Female
Pronouns: She, her, hers
Race/Ethnicity: White/Caucasian
Date of Visit: Monday, 10/4/2021 @ 1600
Advanced Directives/Power of Attorney: N/A
Insurance: Private Insurance via Employer
Primary Care Provider: Morgan Longtin,
DNP-FNP at Essentia Health
Source/Reliable Information: Self/100%
Referral: No referral
Subjective:
Chief Complaint:
M. X. stated she presented to the clinic today because, “My right ear feels like it is full of
something, is pretty painful, and muffles most sounds I hear. It is harder hear in my right ear.”
History of Present Illness (HPI):
M.X. presents to the clinic today after having pain and loss of hearing in her right ear that started
about 4 days prior. She reports that it feels as if her ear is full of something, and that sound is
muffled in that ear. M.X. reports the pain in her right ear at a 5/10 on a 0 to 10 numerical pain
scale with 0 being no pain and 10 being the absolute worst pain of her life. She states that warm
compresses to that ear/side of her head do relieve the pain somewhat to maybe a pain rating of 3-
4/10 but that no other intervention such as NSAIDs, Tylenol, rest, or certain positions improve
her symptoms, or the pain experienced. She states that nothing really seems to make it worse or
increase her pain, and that it is just a continuous, constant, and persistent ache and throbbing pain
that doesn’t go away or improve/worsen during the day. The pain does wake her up at night at
times and does make it hard to fall back to sleep, though the warm compress does sometimes
alleviate it enough so that she can fall back to sleep. In addition to the pain and fullness, M.X.
reports that the ear at times feels very itchy and irritated.
M.X. denies any upper respiratory symptoms or manifestations and a recent cold or respiratory
infection within the last couple weeks or even within the last 2-3 months. She does report that
there was zit or pimple in her ear about a week ago or so that she did pop with her fingers once it
was ready. She also reports taking a bath with her daughter 5-6 days ago and that during the bath,
her daughter accidently poured water directly into her ear a couple times while playing. She
denies any external ear redness or pain that she is aware of and that she has not noticed any
external drainage or fluids dripping out of her ear. She denies any fever, chills, rash, headache,
nausea, vomiting, diarrhea/constipation, conjunctivitis, rhinitis, tinnitus, history of ear infections,
history of chronic rhinosinusitis, or any other symptoms present in any other systems except her
ears.
