Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, typically involving ear pain or discomfort:
Ear pain (especially in young children who may be unable to verbalize it – presenting with pulling or tugging at the ear)
Fever
Fussiness or irritability (in infants)
Difficulty sleeping
Decreased hearing (conductive due to middle ear fluid)
Feeling of fullness or pressure in the ear
History of Present Illness:
Onset and duration of symptoms
Severity of pain (graded on a scale for verbal patients)
Associated symptoms (cough, congestion, runny nose)
Recent upper respiratory infection (URI)
Past medical history (previous ear infections, allergies, craniofacial abnormalities)
Vaccination history (pneumococcal conjugate vaccine)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be elevated with fever.
Ear examination (otoscopy):
Tympanic membrane (eardrum): Look for redness, bulging, opacity, or purulent fluid behind the eardrum.
Pneumatic otoscopy (using a pneumatic otoscope) may be performed to assess mobility of the eardrum.
Anterior rhinoscopy (examination of the nostrils) – May reveal signs of upper respiratory infection (URI).
Assessment:
Based on the clinical presentation and otoscopic examination, diagnose acute otitis media (AOM).
Consider the severity of the infection (uncomplicated, with effusion, or with perforation).
Identify potential risk factors (age, daycare attendance, recent URI, craniofacial abnormalities).
Plan:
Antibiotics: Oral antibiotics are typically the mainstay of treatment for AOM. The specific choice and duration will depend on factors like age, severity, and local resistance patterns.
Pain management: Over-the-counter medications like acetaminophen or ibuprofen for pain and fever reduction.
Nasal decongestants (short-term use only): May be helpful to relieve nasal congestion and improve drainage.
Warm compresses: May provide some comfort for ear pain.
Instructions:
Administer antibiotics as prescribed, following the recommended dosage and duration.
Give pain relievers as needed for fever and discomfort.
Use nasal decongestants as directed (if prescribed), but avoid prolonged use.
Encourage frequent ear drops (if prescribed).
Monitor for improvement in symptoms.
Progress Notes:
Document daily assessments including temperature, pain level, ear drainage, and response to treatment.
Note any changes in otoscopic findings.
Update the plan as needed based on the patient’s progress.
Discharge Instructions (for patients with improving symptoms):
Complete the full course of antibiotics even if symptoms improve.
Monitor for any signs of worsening (increased pain, fever, purulent drainage).
Apply warm compresses for comfort (if helpful).
Maintain good hygiene practices to prevent future infections.
Follow up with a healthcare provider for re-evaluation in (#) days (adjust based on severity).
Consideration for Referral:
Infants under 6 months old with AOM
Patients with severe symptoms or complications (mastoiditis, facial nerve palsy)
Patients with recurrent AOM (may require further evaluation or specialist referral)
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of acute otitis media.