Ear Disease PE (e.g., Otitis Media, Tympanosclerosis)

Subjective:
Chief Complaint:
Chronic ear wax buildup and nasal congestion

History of Present Illness:
Elliot presents with c/o chronic ear wax buildup and nasal congestion. Hx of two surgeries, first in 2016 and second in 2018, with prior ENT involvement. Reports ongoing issues with ear wax accumulation, described as uncomfortable but not affecting hearing. Nasal congestion is noted to be persistent, with occasional post-nasal drip. No hx of allergies or use of nasal sprays. No reported sleep disturbances or snoring. Pertinent negatives include no trouble with hearing as a result of wax buildup.

Past Surgical History:
Hx of two surgeries: first in 2016 and second in 2018, with prior ENT involvement.

The Review of Systems:
ENT: Persistent nasal congestion with occasional post-nasal drip. No concerns about sleeping, no waking up much in the night or trouble breathing, no snoring after surgery. No significant increase in nasal congestion during high allergy seasons.

Current Medications:
Not using any medications at the moment. No use of nose sprays.

Allergies:
No noticeable allergies.

Objective:
Physical Examination:
Ears:
- Inspect auricle: Normal
- Otoscope examination:
  - Tympanic membrane:
    - Light reflex: Visible
    - Handle of malleus: Visible, vascularity normal
    - Drum: Translucent, contour normal
    - Attic retraction pocket: Absent
  - Rinne test: Not assessed
  - Weber test: Not assessed

Assessment:
Problem:

1. Chronic cerumen impaction (380.4) with associated dry skin in the ear canals, contributing to wax buildup. Persistent nasal congestion with occasional post-nasal drip.

Differential Diagnosis:
1. Chronic cerumen impaction (380.4) secondary to dry skin or eczema in the ear canals.
2. Allergic rhinitis (477.9) contributing to nasal congestion.
3. Chronic rhinosinusitis (473.9) as a potential cause of persistent nasal symptoms.

Plan:
  
The patient has dry wax and dry skin in the ear canals, though no hearing impairment has been reported.  
  
- Advised the patient to apply oil in the ears a couple of times per month to prevent dry skin buildup.  
- Recommended placing a cotton ball in the ear after applying the oil and lying down to allow proper absorption.  

  
The patient reports persistent nasal congestion with occasional post-nasal drip.  
  
- Prescribed a nasal spray with instructions to use 2 sprays in each nostril daily.  
- Provided education on the appropriate long-term use of nasal spray, emphasizing the importance of avoiding overuse of decongestant sprays to prevent rebound congestion.  
- Referred the patient to an allergy specialist located closer to their home in xxx for further evaluation and management.