Assessing the Ears, Nose and Throat

Assessing the Ears, Nose and Throat Patient name: James

Age: 11

Gender: M

SUBJECTIVE DATA: Chief Complaint (CC): Case 3 – mild earache.

History of Present Illness (HPI): James is brought to the clinic to have his right ear checked.

He complains of a mild earache for the past two days. His grandmother believes that he felt 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. He has been spending most of his summer in the pool.

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6512 WEEK 5 DISCUSSION: ASSESSING THE EARS, NOSE, AND THROAT Medications: None.

Allergies: None Past medical history: None Past surgical history: None Personal/ social history: The patient stays with his grandmother. He goes to school normally like other children his age. He has no troubles making friends.

Immunization history: He is up to date with his vaccinations.

Significant family history: He lost both of his parents in a road accident. His grandmother is hypertensive.

Review of Systems: General: Fever.

HEENT: Reports an earache on his right ear. It worsens when he sleeps and makes it hard for him to hear. He denies any changes in vision.

Respiratory: Within normal ranges.

CV: Within normal limits. No chest pains, murmurs or palpitations.

GI: Within normal limits. No abdominal pain, nausea or vomiting.

GU: No dysuria or increased frequency.

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6512 WEEK 5 DISCUSSION: ASSESSING THE EARS, NOSE, AND THROAT MS: No weakness, pain or myalgia.

Psych: No history of anxiety, depression, disturbance or mental health history. Denies any feeling of dizziness.

Neuro: Intact Integument/Heme/Lymph: Intact.

Endocrine: Intact.

Allergic/Immunologic: None.

OBJECTIVE DATA Physical Exam: Vital signs: B/P 128/78, oxygen saturation 90, HR 110, P 65 and regular; T 98.0 orally; RR: 18 non-labored; temperature 39.0, height 4’’6, weight 40 Kgs. General: AA&O x4. Fever +.

HEENT: Erythematous right ear with a prominent tan.

Chest/Lungs: Within normal limit.

Heart/Peripheral Vascular: Regular heart rhythm. No arrhythmia. No murmurs.

ABD: Normal bowel sounds. Non-distended. No hepatomegaly.

Musculoskeletal: Within normal limit.

Rectal: deferred.

Neuro: CN intact Skin/Lymph Nodes: No cracks, rashes or lesions on the skin. Palpable lymph nodes.

ASSESSMENT: Lab Tests and Results: None Diagnostics:

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6512 WEEK 5 DISCUSSION: ASSESSING THE EARS, NOSE, AND THROAT

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1. Full blood count.

Differential Diagnosis: 1. Otitis externa – Otitis externa, also known as swimmers ear, is an ear infection common in children who spend most of the time in water (Fischer & Dietz, 2015). Excessive moisture in the ear irritates the ear and sometimes break the cerumen skin barrier on the canal causing viral, fungal or bacterial infections. Inflammation of the external auditory canal characterises it.

Hearing loss can occur if the edematous or filled with debris (Mann, 2017).

2. Acute otitis media - This type of ear infection is common in infants and children and is characterised by middle ear effusion and inflammation of the tympanic membrane (Kitamura et al., 2015). It is commonly associated with viral upper respiratory tract infections and can be prevented by pneumococcal vaccination (Mann, 2017).

3. Object in the ear – This is another common cause of an earache in children. Children tend placing objects in the ears or some cases insects or objects accidentally enter the ear. This results in pain, irritation, and discomfort. It also increases the risks of secondary ear infections (Mann, 2017).

PLAN: Treatment with antibiotics and pain medications.

6512 WEEK 5 DISCUSSION: ASSESSING THE EARS, NOSE, AND THROAT References Fischer, M., & Dietz, A. (2015). Acute external otitis and its differential diagnosis. LaryngoRhino-otologie, 94(2), 113-25.

Kitamura, K., Iino, Y., Kamide, Y., Kudo, F., Nakayama, T., Suzuki, K., ... & Uno, Y. (2015).

Clinical practice guidelines for the diagnosis and management of acute otitis media (AOM) in children in Japan–2013 update. Auris Nasus Larynx, 42(2), 99-106.

Mann E. (2017). How to diagnose and manage primary and secondary earache and ear infections. The Pharmaceutical Journal, 298(7900). doi: 10.1211/PJ.2017.20202483.

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