Assignment: Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

Assignment: Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

Assignment: Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

Case 3: Focused Ear Exam

Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

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Case 3: Focused Ear Exam

Episodic/Focused SOAP Note Template

Patient Information:

J.M., 11yrs, M, W

S.

CC (chief complaint): bought in by grandmother with a complaint of right ear pain. Pain is described as mild but gets worse at night. The patient states that pain interrupts his sleep and it is harder for him to hear.  Pt states that the pain started two days ago. Pt also stated that he spent a lot of time in the pool over the summer. Questionable fever. The grandmother stated that the patient felt warm but did not check temperature with a thermometer.

Permalink: 

HPI:11-year-old-W male accompanied with the grandmother. Complain of right ear pain that started two days ago. Pain is mild but worse at night with interruption with sleep. Pt had spent a lot of time in the pool over the summer. Pt does have a prominent tan. Pt has only taken Tylenol 650mgx1 with no relief from pain. Pain is a 7/10 on a pain scale. Pt is having a problem with hearing in right ear.

Current Medication: Tylenol 650mg for pain as needed. Multivitamin one gummy daily for wellbeing.

Allergies: No Known Allergies

PMHx: all immunizations are up-to-date. No past illness or surgeries. Has not been sick besides having a common cold that lasts less than a week.

Soc Hx: pt goes to public school five days a week. Participates in sports activities in school, which includes wrestling and swimming. Enjoys swimming, playing video games, and playing with friends. Denies smoking tobacco and marijuana. Denies during any illicit drugs. Lives with both parents and one older sister (16yrs of age). Wears a seat belt while in a motor vehicle. Feels safe at home. Visits grandparents every summer.

Fam Hx: Both parents are in good health. Mom a Nurse Practitioner. Dad is a lawyer. Sister a full-time student at a local high school also on the swim team. Sister is in good health.  Grandmother a retired nurse in good health. Grandfather retired Navy. Previous smoker of 1 pack of cigarettes daily. Quit 5 years ago. Occasional drinker. Drinks one shot glass of vodka once a month. Dad has hypertension that is controlled with diet and exercise.

ROS:Martha brings her 11-year old grandson, James, to your clinic

GENERAL:  No weight loss, chills, and fatigue.pt have a fever of 101.0 F Has pain in the right ear. Right ear is red and tender to touch.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears: right outer ear red, tender to touch, the right inner ear is red with some clear drainage. Some hearing loss noted in the right ear. Left ear is non-tender, no drainage, no redness is noted. The left hearing is intact.  Nose: clear with no secretions. No sneezing or congestion Throat: no hoarseness, redness, or soreness.

Assignment: Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

SKIN: No rash, or bruising. Tan is noted without any peeling at this time.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or tenderness.

GENITOURINARY:  no pain on urination. Urine is clear and yellow. Not cloudy

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  Some enlarged nodes noted on the right side of the neck. No history of splenectomy

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis. No known allergies.

O.

Physical exam: right ear is noted to be red and tender to touch with some clear drainage and swelling noted in the right ear canal. Right neck tender with swollen lymph nodes. No nasal congestion or a runny nose is noted. Lung sounds are clear on auscultation. Vital signs are temp 101.0 F, blood pressure 110/65 respiration 20 pulse 75. Skin is warm and dry to touch. Prominent tan is noted without any peeling at this time.

Diagnostic results: WBC: 15,000/mm3. Normal white blood cell count for a child 11 years of age is5,000 to 10,000/mm3. A high WBC may indicate an infection (University of Rochester Medical Center, n.d.). Ear culture of the drainage. Abnormal fluid in the ear canal may have bacteria or fungi presence and may pose a risk for recurrent infections (American Academy of Otolaryngology-Head, and Neck Surgery Foundation., 2018). Examination of the ear canal with an otoscope. The ear canal is red and swollen on examination.

Assignment: Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

A. Martha brings her 11-year old grandson, James, to your clinic

Differential Diagnoses: Swimmers ear (otitis externa). Acute otitis externa is a common disease of children and adolescents that is defined by diffuse inflammation of the external ear canal (Hui, 2013). It is the primary cause of ear infection associated with swimming (Hui, 2013). Signs and symptoms are a pain, a sensation that the ear is blocked or full, drainage, a decrease in hearing, and fever.

Acute otitis media. Is the most common occurring inflammatory diseases of infancy and childhood that involve the middle ear and some involvement of the tympanic cavity (Thomas, Berner, Zahnert, & Dazert, 2014). Signs and symptoms include ear pain and impairment in hearing.

 Acute bacterial rhinosinusitis. An infection of both your nasal cavity and sinuses that is caused by bacteria that causes the sinuses and nasal cavity to become inflamed (Cedars- Sinai, 2018). It causes facial pain, ear pressure and/or fullness, and fever (Cedars- Sinai, 2018).

P.

Ear drops that are mixed with an antibiotic and hydrocortisone to fight infection and reduce inflammation for pain and fever over the counter pain relievers can be given.

Assignment: Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

References

References- Martha brings her 11-year old grandson, James, to your clinic

American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2018). Swimmer’s Ear (Otitis Externa). Retrieved from ENT Health: https://www.enthealth.org/conditions/swimmers-ear-otitis-externa/.

Cedars- Sinai. (2018). Acute Bacterial Rhinosinusitis. Retrieved from Cedars-Sinai: https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/acute-bacterial-rhinosinusitis-1.html.

Hui, C. P. (2013, February). Acute otitis externa. Paediatr Child Health, 18(2), 96-98. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3567906/.

Thomas, J. P., Berner, R., Zahnert, T., & Dazert, S. (2014, February 28). Acute Otitis Media—a Structured Approach. Deutsches Arzteblatt International, 111(9), 151-160. doi: 10.3238/arztebl.2014.0151.

University of Rochester Medical Center. (n.d.). White Cell Count. Retrieved from Health Encyclopedia: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=white_cell_count.

Martha brings her 11-year old grandson, James, to your clinic

Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past two days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.

Assignment: Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

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