Overview
Maeve, a 28-year-old female with limited access to dental care and no dental insurance is seen with a chief complaint of right temporomandibular pain causing pain in the right ear.
Other diagnosed conditions include sleep bruxism, sleep disorder, and dental caries. She presents to a general medical clinic with a chief complaint of right ear pain that has been more or less continuous for the past month. No problems with hearing or balance. Also complains of pain with cold liquids in her lower left molars for brief time periods.
She was recently diagnosed with depression and is taking paroxetine, a selective serotonin reuptake inhibitor, 20 mg per day, which has helped her mood. Although her sleep has recently improved, she still awakens after only 3 hours of sleep every other night and finds it difficult to go back to sleep.
She has not been to a dentist since she went off her parent's dental plan about 6 years earlier.
Her ear pain is beginning to have a large negative impact on her life, and she is finding it difficult to concentrate at her job and in her night school courses.
Background
Setting
Primary care clinic.
Patient
Maeve, a 25 year old unemployed female – former/returning student.
Health Provider
49 year old male dentist/ physician/nurse practitioner/other.
Initial visit with Provider
Maeve and her health care provider sit across from each other.
Maeve's doctor says, "Good morning Ms. Jones, what brings you into our clinic today?"
Maeve replies, "Well, I was doing fine until two months ago, when I started having some pain in my right ear. At first it wasn’t bad, but then it got worse. Today it is really bothering me."
"I am sorry to hear about your suffering," her doctor says. "Did it seem that the start of the pain was due to any particular event?"
"No, not that I can think of," Maeve replies.
"Please tell me what else has happened over the past 2 months," her doctor requests.
Maeve says, "Well, I can’t think of much else except that I have a lot of pain."
The doctor nods. "Ok. May I ask you a few questions about this ear pain?"
"Of course," says Maeve.
Electronic Health Record
How the electronic health record (EHR) would appear at this point:
ID
25 year old Caucasian female. Good historian.
CC
Right ear pain for 2 months. Insidious onset – precipitating factors – stress?
HPI
Patient was well until 2 months ago, when she noted low-level pain in her right ear. Her pain frequency and intensity substantially increased over the past 4 weeks, especially during the past week, and she now has constant pain. The pain is worst in the morning.
