Physical Assessment Discussion Paper
Chief Complaint (CC): “My left ear pains.”
History of Present Illness (HPI): AF is a 7-year-old Caucasian male who presented to the clinic with his father. His Father said he had found in the last few days that AF had sometimes been pulling his left ear. In the past four months, the son had ear infection with ear ache. He also said that he gave the patient ibuprofen to relieve the pain but did not help. Dad said that AF was recuperating from a flu-like symptom, runny nose, and lack of appetite, congestion and slight cough when sneezing and lying down. Additionally, the client’s father reports that AF has white spots on the tongue that began four days ago. The father denies his son having abdominal pain, diarrhea, constipation, nausea, vomiting, and sore throat. Physical Assessment Discussion Paper
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Medications:
- Ibuprofen as required
- Tylenol as required
Allergies: None
Past Medical History (PMH):
No admission and Acute Otitis media (AOM
Past Surgical History (PSH):
- None
Sexual/Reproductive History:
- None
Personal/Social History: AF stays home with his 4-year-old sister, and dad. He is in grade two and completes a full day of classes. He performs really well in class, has several friends and has never had any disputes with peers. The family typically consumes a well-balanced diet and rarely dines out. AF loves cycling and uses a helmet at all times. He watches a TV show every night and spends nearly an hour playing video games on his computer. He sleeps around nine hours at night. His dad often drinks beer, but he denies using cigarettes or illicit substances. Father said they usually wear safety belts when driving.
Immunization History: His immunizations are up to date; he received his influenza vaccination in October 2019.
Family History: patient’s Mother is deceased from hypertension and maternal mother is deceased from diabetes mellitus. Paternal grandmother died from dementia. Father and sister are alive and healthy with no medical history. Physical Assessment Discussion Paper
Review of Systems:
General: AF reported that his ear had been paining since he got up. Father said the client had been complaining all day. No weakness or weight loss.
HEENT: patient complains of ear pain. No changes in hearing or vision. No runny nose, congestion, or sneezing. No drainage from ears.
Respiratory: Denies cough or shortness of breath.
CV: Father denies any cardiac issues.
GI: No vomiting or nausea. Father reports a decreased appetite. Denies diarrhea or constipation or. Bowel movements are normal.
GU: No change in his urinary pattern, incontinence. No dysuria or hematuria
Allergic/Immunologic: No food allergies, hay fever, or asthma. No immunosuppression or seasonal allergies.
OBJECTIVE DATA
Physical Exam:
Vital signs: Pulse: 99/min, BP 97/65 left arm, RR 18, Wt: 48 lbs; Ht: 47”; BMI: 15.3.
General: AF appears ill coughing, has a runny nose and keeps pulling on his left ear. The patient is attentive and makes good eye contact. The child appears slightly distressed, but looks well-nourished, hydrated, and well-groomed.
HEENT: The head is normal-cephalic and the hair is uniformly distributed. PERRLA, red reflux visible bilaterally, pale pink conjunctiva, white sclera. There is no sclera or conjunctival injection. Ear examination shows left ear erythematous tympanic membrane, translucent, without discharge or pus. The right ear tympanic layer is clear, bulging, red, and full of pus. Slight nasal congestion observed on the maxillary, frontal, rhinorrhea, sneezing, clear postnasal drainage. Throat is a moist pink mucous membrane.
Neck: No lymphadenopathy. Appropriate ROM.
Chest/lungs: Has an occasional incident of coughing x1, no shortness of breath observed at rest or exercise. The lung area is bilaterally clear on auscultation. No rhonchi, rales or wheezing. The chest is bilaterally symmetrical.
Cardiovascular: S1 and S2 heart sounds intact. Pulse equal x2 extremities.
No murmurs or gallops noted Capillary Refill is less no lower extremity edema, or peripheral cyanosis noted
Abdomen: Bowel sounds are present either in quadrant, no splenomegaly or hepatomegaly. – The abdomen of the patient is soft, non-tender, and non-distended. No rebound rigidity or tenderness of bowel sound. Physical Assessment Discussion Paper
ASSESSMENT:
Primary Diagnosis
Acute otitis media: this is a primary diagnosis according to my exam results that include erythema and bulging tympanic membrane with reduced movement, rendering it impossible to distinguish landmarks. Both of these are the typical symptoms of acute otitis media along with other indications including nausea, reduced appetite, vomiting and fever.
Differential Diagnosis
Otitis Media with Effusion (OME): This is the first differential diagnosis that caught my attention. OEM involves a sticky or thick discharge that appears without an ear infection in the middle ear behind the eardrum. It sometimes results from the impairment of the Eustachian tube. Muffled hearing complaints or a feeling of heaviness in the ears are frequent concerns about this condition, although there are also no visible signs of this. This diagnosis was ruled out as the patient has no hearing problems
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.Acute bacterial sinusitis: It is normally caused by a viral upper respiratory infection. Fever is normally associated with this condition following an existing respiratory condition of at least ten days (Ward, et al. 2013). Headache, tenderness of the frontal and maxillary and sinus cavities due to congestion and irritation of nasal cavities with edematous, as well as headache are some of the clinical manifestations (Ward, et al. 2013). The patient’s father claimed that the patient is getting over cough and cold that may result in the sinus problems.
PLAN:
According to Choffor-Nchinda et al. (2018), the first-line antibiotic for the treatment of acute acute otitis media (AOM) in adults and children is amoxicillin (, dose for AF is 90 mg twice everyday for 10 days. Education for the patient to complete the 10-day program is necessary even when the patient starts feeling better. Parent should proceed with -ibuprofen and tylenol for pain and fever, if required. Patient’s father was directed to follow up in days if symptoms escalate or when the patient does not improve.Physical Assessment Discussion Paper
Health Promotion/Disease Prevention: The value of keeping up with vaccines, like influenza vaccination, was clarified. O annual child visits and dental examinations should be done on a preventive dental basis every 6 months. The significance of keeping the diet balanced and the detrimental consequences of an unhealthy diet were also discussed.
Reflection:
This clinical experience was very enlightening. I did not believe I was going to consider it, and the particular reasons for the acute otitis media treatment are continually being developed in more depth. This treatment option is dedicated to increase daily productivity of the patient. Therefore, in coordination with my preceptor I made the required clinical procedure to achieve a rational primary, differential diagnosis and treatment strategy for the patient. I would not have made any other choice, since I felt I have done extensive evaluation with my preceptor on the patient’s health problem.
References
Center for Disease Control (CDC), (2018). Otitis media with effusion. Retrieved from https://medlineplus.gov/ency/article/007010.htm
Choffor-Nchinda, E., Atanga, L. C., Nansseu, J. R., & Djomou, F. (2018). Effectiveness of amoxicillin alone in the treatment of uncomplicated acute otitis media: a systematic review protocol. BMJ Open, 8(6), e021133. https://doi-org.ezp.waldenulibrary.org/10.1136/bmjopen-2017-021133
Ward, E., Applegate, K., Bordley, C., Darrow, D., Glode, M., Marcy, M., . . . Weinberg, S. (2013, July). Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. American Academy of Pediatrics Clinical Practice Guideline, 132(1), e262-e280. doi:10.1542/peds.2013-1071
Physical Assessment Discussion Paper