(2) Patient Information:
Paddy, 4yrs, M, Caucasian and insurance not provided
CC: Ear ache
HPI: Paddy is a 4yr old male child brought to the clinic with c/o ear ache since morning. According to the mother he had a cold for a few days and has been c/o about his ear popping and feeling stuffy. This morning he c/o ear pain and his mother feels he is febrile too.
Onset: Today morning.
Location: Left ear
Duration: Continuous pain
Characteristics: Pain 3/5 on the visual pain scale. Stabbing pain.
Aggravating Factors: None reported
Relieving Factors: Medication
Chewable children’s multivitamin with iron I tablet PO daily.
PMHx: Pregnancy: Full term. Twin gestation, NSVD. Weight: 5 …show more content…
No tenderness on pinna/tragus bilaterally. Nose: Patent nares. Mouth: Pharynx with clear drainage, tonsils 2/4 on both sides. No loose teeth.
NECK/LYMPHATIC: Neck: Supple. Non-tender- posterior cervical nodes. Lymphadenopathy on preauricular nodes. Thyroid small, firm and in midline.
Cardiovascular: Heart: RRR w/o murmur.
Respiratory: Respiration unlabored. Lungs clear on both sides
Gastrointestinal: Abdomen soft, round and non-tender with active bowel sounds. (-) Masses. (-) Organomegaly.
Diagnostic results: None available
Acute otitis media (AOM) (ICD 10: H66.92): Otitis media is an infectious and inflammatory condition of the middle ear. It is one of the leading causes of health care visits as well as one of the important preventable complication of hearing loss. Children with acute otitis media will present with acute signs and symptoms of otalgia and fever. The signs and symptoms include fever, otalgia, irritability, otorrhea, lethargy, anorexia, and vomiting (Daniel et al., 2014). In most cases, AOM is a complication of eustachian tube dysfunction that takes place during a viral upper respiratory tract infection. In most cases of AOM, bacteria is the causative organism (Harmes et al., 2013).
Pertinent positives: Left ear tympanic membrane bulging, recent h/o cold and no tenderness on the pinna/tragus, recent onset of ear pain.
Pertinent Negatives: None. P.
Diagnostics: Diagnosis of ear infection usually made by pneumatic otoscopy
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Normocephalic atraumatic. Pupils equally round and reactive to light, extraocular motions intact. Oral cavity shows oropharynx clear but slightly dried mucosal membranes. TM (tympanic membranes) clear. Neck, supple. There is no thyromegaly, no JVD. No cervical supraclavicular, axillary, or inguinal lymphadenopathy.
PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.
American Academy of Pediatrics and American Academy of Family Physicians article regarding acute otitis media is a filtered resource. It is an appropriate source for nursing practice because; it establishes clinical guidelines to diagnose and manage AOM. It also establishes guidelines when to treat the signs and symptoms of AOM, watchful waiting, or to treat with an antibiotic. This article is classified as an evidence based guideline because, it reviews multiple research literatures in a systemic manner and provides
The prescribing of antibiotics for AOM can have an impact on the health of the treated children and increases the cost of providing care. Watchful waiting is the recommendation from the AAFP & AAP in cases of uncomplicated AOM that are a result of other illnesses such as an upper respiratory virus. In the past doctors would immediately prescribe antibiotics for the signs and symptoms of an ear infection, however new evidence shows that over time bacteria have become resistant to certain antibiotics and so other means of treatment must be explored. If a child presents with symptoms of AOM and has no other underlying illness or condition, then watchful waiting is an appropriate avenue of treatment for the child. The research showed placebo trials had favorable outcomes and children responded without antibiotic interventions. If watchful waiting is used the child is not exposed to unneeded antibiotics and this reduces the chances of antibiotic resistance in the future. In addition, it also reduces the amount of money spent on health care needs in the form of purchasing medications. It should be noted that watchful waiting should only be considered in cases of uncomplicated AOM and that education should be given to care givers on when to follow up if symptoms do not improve within 48-72 hours. In the even that symptoms do not resolve then antibiotics may become necessary.
I did talk with him about my concern regarding the lesions that are close to the eye and I felt it was very important that he be seen by ophthalmology and this was arranged for him today. He will keep that appointment this afternoon over at Eyesight. I talked about antiviral therapy as he is within a couple days of the onset. He was written for Valtrex 1000 mg three times daily for seven days. In addition, prednisone 10 mg tablets, 40 mg for two days, then 20 mg for two days, then 10 mg for two days. I reviewed the case with Brett Rankin, MD, as I was concerned with the lesions in the ear and my concerns regarding the possibility of this leading to a Ramsay Hunt syndrome. Currently as his hearing is unchanged and there is no facial paralysis issues, I am hoping that will not be worry with the steroids and the antiviral therapy starting. Dr. Rankin talked about doing a hearing evaluation to ensure there is no asymmetry between his two ears, even though the patient perceived that his hearing was okay and that will be arranged for him. He knows he will be contacted by Dr. Rankin's office for that. He knows to contact me if his symptoms worsen in any way. We did talk about the potential complications and he is aware of what to be looking for. A viral culture was performed to confirm the diagnoses, but he understands that may take time to return the results to us. He will monitor symptoms in the
Acute Otitis Media (AOM), inflammation or infection of the middle ear, is an illness most parents have had experience with. Countless hours of lost sleep and worry secondary to their child’s pain and distress can keep even the most seasoned parents awake at night. Before the age of 36 months, 83% of children will experience 1 or more ear infections and AOM is the most common reason for office visits of preschoolers in the United States (Zhou, Shefer, Kong & Nuorti, 2008). The graphic below serves as a review of evidence and explores the usefulness of the information in relation to the option of watchful waiting in the management of AOM.
Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2
Otitis media (OM) is the main source of ear disease in Indigenous children (AIHW, 2014). OM can lead to fluctuating hearing loss and it usually does not show any symptoms so that detect without specialist screening is difficult (AIHW, 2014). Indigenous children’s development and schooling would be seriously affected as early childhood hearing loss is detrimental to brain development, lead to low language development and poor social development (AIHW, 2014). In Aboriginal and Torres Strait Islander children, the disease embodies early, often within the first two weeks of life, and usually presents as middle ear effusion, or glue ear (AIHW, 2014). The reasons for high rates of ear disease in Indigenous children are household overcrowding, passive smoking, premature birth, bottle feeding and malnutrition (AIHW, 2014). For the improvement measures, Haemophilus influenzae type b (Hib) vaccination and routine child ear and hearing check can help to improve these ear diseases (AIHW,
Present Illness- Miss B reports left ear pain for the past two day. She states that the pain started as a dull left sided ache that was a 2 on the 0 out of 10 verbal pain scale and has slowly progressed to a 7 at present. She relates the pain as an ache that is not aggravated or relieved by anything. Miss B reports that she was unable to attend school today due to ache and came in for treatment. She reports that she has taken an over the counter pain reliever, unknown name and dosage, with little relief. She denies fever, nausea, vomiting or diarrhea. Miss B does report that she has not been eating as much as it seems to hurt to chew but denies difficulty swallowing. She denies change in hearing, ear canal discharge and dizziness during the ache.
History of Present Illness: Per patient report, he was in his usual state of good health until 2 days ago when he started feeling a throbbing throat pain. The pt denies pain in any other part of his body. The sore throat is al most constant and states feeling a throbbing sensation. Aggravating factors are swallowing and talking. The patient feels some short relief when he takes lozenges or eats something cold. Pt states awakening at night due to the throbbing throat pain. Currently, the pain level is 7/10 in a numeric scale (0-10). Denies any other associated symptoms such as headache, fever, chills, drooling, problem swallowing, hoarseness, sneezing, runny
Head and Neck: Patient skull is of normocephalic, atraumatic and without masses. The patient 's facial expression and facial contours are normal. The parotid glands are normal. The sinuses are non-tender. Palpation of the temporal and masseter muscles reveals normal strength of muscle contraction. There is symmetry of the nasolabial folds. There is no facial droop noted. Trachea midline. Thyroid is smooth, no goiter or