NC cerumen.pdf - Subjective findings: ● Chief Complaint: “I...

Subjective findings:
● Chief Complaint: “I can’t hear as well”
● History of Present Illness: NC is a 73 y/o male who presents today for bilateral “clogged”
ears. He reports decreased hearing and a history of cerumen impaction. He reports he
routinely gets his ears flushed every year. He has bilateral hearing loss L>R. He denies
any recent URI symptoms, PND, fatigue, use of hearing aids, fever, earache, cough, or
n/v/d. He has not tried any medication or home remedies. Pt reports he has not yet taken
his BP medication this AM.
● Medications: Linsinopril 10mg daily
● Allergies: NKDA
● Past medical history: HTN
● Surgical history: None
Review of Symptoms (ROS)
● General:. Denies any recent fever, cough, or change in weight
● HEENT: +hearing loss L>R. Denies head injury, headache, tinnitus, PND, or earache.
Denies frequent colds, nasal stuffiness, or sinus problems.
● Pulmonary: Denies cough or SOB
● Cardiac: Denies chest pain, SOB, or palpitations
● GI: Denies N/V/D/C
(O) Objective Findings:
Vital signs:
● BP: 160/80
● HR: 103
● SpO2: 98%
● RR: 18
Physical Exam:
● General: Well nourished and well-groomed.