Otitis externa

Patient comes in again today because of ear symptoms that have returned after finishing Cortisporin drops. He also has a significant history of pruritus and rash that Dr. is treating for him with Olivamine lotion. This is working well for him. He denies any complaints of skin problems today other than a small patch on his thumb that is his classic sign of his rash although it is very mild today. He is mainly here because of increasing complaint of ear infection. He has a history of multiple external otitis infections that he has tried multiple drops and oral Diflucan as well as other treatments to resolve. He uses Flonase on a regular basis two sprays each nostril twice daily as well as Zyrtec for itching if needed although antihistamine seemed to increase his prostate problems. He also has a history of chronic idiopathic urticaria that he uses topical Benadryl solution for and seems to resolves with that.

ASSESSMENT:
1. Lichen simplex chronicus, controlled.
2. Otitis externa.
3. Eosinophilic esophagitis.
4. COPD.

PLAN:
1. At this time, he has the ear drops. I encouraged him to continue using these. We can, in the future, prescribe him a mycotic ointment like clotrimazole to see if that can resolve his ear symptoms as well. He would like to go to Dr. his otolaryngologist to further identify what is going on with his otitic complaint as they have treated this before and may be able to better treat it today. He does have a history of fungal infection from the Philippines that he thinks may be responsible.
2. We will follow up with him as needed for his pruritus and rash complaints to see if there is any other treatment that can help maintain his symptoms.
3. We will follow up on an as-needed basis this winter for his complaints.

Advertisements

Leave a Reply