Hl Case Study

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(2) Patient Information:
Paddy, 4yrs, M, Caucasian and insurance not provided
S.
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
Treatment: Tylenol
Current Medications:
Chewable children’s multivitamin with iron I tablet PO daily.
Allergies: NKDA
PMHx: Pregnancy: Full term. Twin gestation, NSVD. Weight: 5
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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
A.
Differential Diagnoses:
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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