Ear pain without ear infection

Template

Tap a choice or type a Repertoire Line to see how the note changes. Defaults are what the template inserts on its own.

Try a Repertoire Line

Practice wording only: leave out patient details. Nothing typed here is saved or sent.

ExamChoose one

Likely causeChoose one

PlanChoose any

ReferralChoose any

Follow-upChoose one

Counseling

The ears do not show an infection today, so antibiotics are not needed. Recommended supportive care with tylenol or motrin as needed for pain. Ear infections can develop later with a cold. Return precautions given including worsening ear pain, fever, drainage from the ear, ear pain that is not improving, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Ear pain without ear infection
• Tympanic membranes clear without bulging, purulence, or acute otitis media
• Antibiotics not indicated
• Follow up if pain persists more than 2-3 days or fever develops

The ears do not show an infection today, so antibiotics are not needed. Recommended supportive care with tylenol or motrin as needed for pain. Ear infections can develop later with a cold. Return precautions given including worsening ear pain, fever, drainage from the ear, ear pain that is not improving, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

TMs clear without AOM; effusion without bulging doesn't meet AOM criteria
Causes: eustachian tube, referred (throat, teeth, teething), TMJ, canal

Return precautions in the template

worsening ear painfeverdrainage from the earear pain that is not improving

Sources

HealthyChildren.org: Ear Infection Symptoms

Few formal guidelines cover this topic, so the template also leans on expert opinion.