GENERAL APPEARANCE: Well developed, well-nourished, alert, and cooperative, and appears to be in no acute distress.EE EARS: Denies hearing loss, pain, ringing, vertigo, or discharge.
Visual Ear Exam requested by EE for (non-work related) Ear pain.
EE reports ear ****pain/drainage associated with ***** injury (explain)/flu-like symptom*** Fever/ myalgias/malaise/swollen lymph nodes/cough/runny nose/tinnitus/dizziness/hearing changes/recent ear infections/ear drainage over the last ****** days.
Preganent Information: HX of recent +/ - Abx tx for complaint/chronic medical conditions
Current Medications: Denied ****
Female: Denies any chance of pregnancy *****
Focus Assessment: + / - Redness/drainage***/copious amount of wax ****Ear canals and tympanic membranes are clear.
Treatment: Self Selected OTC Medication:
NDC: 0000-0000-00 Lot: Exp:0/202 Dose: Manufacturer OTC Recommendation/OTC
Medication directions, warnings, and directions were available to the employee at the time of the request.
If there is a change in the acute discomfort, the recommendation is to immediately contact your PCP or seek emergency medical services.