SUBJECTIVE DATA
Chief Complaint (CC): “My left ear hurts.”
History of Present Illness (HPI): A 5-year-old Caucasian female with mother. She
states that B.S. started complaining of left ear pain last night and keeps tu
...
SUBJECTIVE DATA
Chief Complaint (CC): “My left ear hurts.”
History of Present Illness (HPI): A 5-year-old Caucasian female with mother. She
states that B.S. started complaining of left ear pain last night and keeps tugging on her
ear. She states that she has not complained until late last night when she started to go to
sleep. B. S. states that her “ear just hurts really bad”. Mother reports that after her bath
last night she attempted to clean B.S. ears out and that seemed to aggravate the pain.
Mother reports that B.S. has had some clear nasal drainage with nasal stuffiness x 3 days
with no fever. Mother states that she gave B.S. some Motrin 5ml and she soon fell asleep.
Mother reports that when B.S. woke up this morning she had a temporal temperature of
101.0F and B.S. was complaining of more pain in that ear. Using the faces pain scale B.S.
indicates that her ear pain made her feel like the third face on the pain scale.
Medications: Motrin 5ml PO once last night.
General: B.S. states that her ear has been hurting all night and she did not sleep
well. Mother states that she woke up this morning crying with fever of 101.0F and
asked to go to the doctor. Mother states she has been whining and wants to be
held, with no interest in playing.
Skin: Reports some mosquito bites on bilateral arms that itch. Denies any injuries
or open sores.
HEENT: Denies headache. Denies vision problems. Denies putting anything into
the ears. Left ear pain, denies drainage. Reports some nasal congestion at times
with clear drainage, reports no pain. B.S. denies any throat pain.
Neck: Denies stiffness or difficulty swallowing.
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