Date:
Patient:
(Chief Complaint): Briefly describe the patient’s main reason for presentation, typically involving ear pain:
Ear pain (often described as throbbing, burning, or itching)
Worsened by touching the tragus (cartilage bump in front of the ear canal) or pinna (outer ear)
May be accompanied by a feeling of fullness or blockage in the ear canal
History of Present Illness:
Onset and duration of symptoms
Severity of pain (graded on a scale)
Associated symptoms:
Drainage from the ear canal (may be clear, purulent, or bloody)
Hearing loss (conductive due to ear canal swelling or blockage)
Tinnitus (ringing in the ear)
Fever (less common)
Past medical history (previous ear infections, eczema, use of ear drops or hearing aids)
Recent water exposure (swimming, showering)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal unless fever is present.
Ear examination (otoscopy):
External auditory canal: Look for redness, swelling, edema, or discharge.
Tympanic membrane (eardrum): May appear normal or show minimal inflammation if the infection hasn’t reached the middle ear.
Assessment:
Based on the clinical presentation and otoscopic examination, diagnose acute otitis externa.
Consider the severity of the infection (mild, moderate, severe) based on pain level, swelling, and drainage.
Identify potential risk factors (recent water exposure, ear canal manipulation, eczema).
Plan:
Ear canal cleaning: Gentle removal of debris and drainage with a bulb syringe and saline solution (if necessary).
Topical otic medications:
Topical antibiotics to combat bacterial infection
Topical corticosteroids to reduce inflammation and pain
Combination otic products (antibiotic/steroid) may be used
Oral pain relievers: Over-the-counter medications like acetaminophen or ibuprofen for pain management.
Avoidance of further water exposure: Use earplugs while showering or swimming.
Instructions:
Instruct the patient on proper ear canal cleaning with saline solution (if applicable).
Apply topical medications as prescribed, following the recommended frequency and duration.
Take oral pain relievers as needed for pain management.
Avoid scratching or inserting objects into the ear canal.
Follow up for re-evaluation in (#) days (adjust based on severity).
Progress Notes:
Document daily assessments including 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):
Continue topical medications as prescribed until completion of the course.
Avoid further water exposure for the recommended period.
Maintain good ear hygiene with proper drying after bathing or swimming.
Follow up with a healthcare provider if symptoms worsen or do not improve within the expected timeframe.
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 externa.