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History

The patient is a 28-year-old female secretary for Center City Chemical. She complains that while she was delivering a message to the loading dock area yesterday afternoon, at approximately 3:30 PM a pallet slipped and a splinter of one of the pallets went into her right ear.

She had no bleeding at the time but did notice some blood on her pillow that night. She complains of slight intermittent pain, decrease in hearing, and slight pain with chewing yesterday but none today. She denies any nasal, sinus, throat, laryngeal, or neck problems.

Past History

ALLERGIES: None.

BLEEDING HISTORY: None.

ILLNESSES: None.

OPERATIONS: TandA as a child.

MEDICATIONS: None.

REVIEW OF SYSTEMS

Not remarkable.

Physical Examination

Heent

NOSE: Nasal mucosa and airway appeared normal.

THROAT: Benign.

LARYNX: Vocal cords appear normal. No hypertrophic lesions seen.

NECK: No palpable nodes.

EARS: Tympanic membrane and canal appeared normal on the left side. Right external auditory canal had an abrasion on the anterior aspect of the canal distally in the canal. Medially in the canal, there was an abrasion on the posterior wall extending on to the tympanic membrane with a small hemotoma on the tympanic membrane. Tympanic membrane appeared to be mobile and intact. Weber test lateralized to the left; difference test was equal; air conduction greater than bone conduction bilaterally.

Impression

Traumatic abrasions of left external auditory canal and tympanic membrane.

Treatment

Patient given a prescription of Cortisporin otic 3 drops q.i.d. in the right ear, #10 cc. Also given a prescription for Audiogram to be done at University Speech and Hearing Center. Patient is to be rechecked after the audiogram.

_______________________________

Nelson Gunter Black, MD

student’s initials

D: current date

T: current date