NR 511 Week 2
Paddy Smith- Age 4 years, male Caucasian, insurance (?)
C.C. “Ear really hurts” has popping stuffy feeling
S.
HPI: Patient presents
... [Show More] with left ear pain and popping and feeling stuffy; recently had a cold. This morning
woke up with stabbing ear pain that is constant a 3/5 on Wong Baker visual pain scale. States pain is
worsened at night laying down and oral Tylenol improves pain somewhat.
Onset: this morning
Location: left ear
Duration: constant
Characteristics: stabbing ear pain
Aggravating factors: worse when laying down
Relieving factors: OTC Tylenol
Treatment: has only tried OTC Tylenol
Severity: 3/5 on Wong Baker visual pain scale
Current Medications: Daily children’s multivitamin + iron; no prescription medications
Allergies: NKDA; food allergies (?), environmental (?)
PMH: Full term NSVD twin gestation 5lbs 2oz.
Immunizations: not specified
Illnesses: none
Surgical History: none
Hospital Stays: not specified
Social History: Attends half day 4K program, doing well and likes school, lives with mother and father;
both work full time, two older siblings (boy age 9, girl age 7), maternal grandparents, and 2 dogs and a
cat.
Sexual History: N/A
Family History: Mother healthy. Twin brother no significant medical history. Older siblings, Father,
Grandparents- medical history not specified
ROS:
CONSTITUTIONAL: No fever
HEENT: Head: no headache; Eyes: not specified; Ears: Stabbing pain in left ear 3/5, denies hearing loss or
ringing in ears. Nose: denies nasal congesting or discharge; Throat: denies sore throat, difficulty
swallowing. Neck: denies enlarged lymph nodes
SKIN: not specified
CARDIOVASCULAR: denies chest pain, palpitation, or dizziness
RESPIRATORY: denies SOB or wheezing
GASTROINTESTINAL: not specified
GENITOURINARY: not specified
NEUROLOGICAL: not specified
MUSCULOSKELETAL: not specified
HEMATOLOGIC: not specified
LYMPHATICS: not specified
PSYCHIATRIC: not specified
ENDOCRINOLOGIC: not specified
ALLERGIES: NKDA
O.
CONSTITUTIONAL: Cooperative, talkative, and appropriate young male who appears his age in no acute
distress.
H- 105cm (41.3 in.), W- 17 kg (37.4lbs) BMI: 15.4 (46th percentile), BP- 102/60, P- 94, R- 18, Sp02- 99%, T99.9 (Tylenol one hour before exam)
HEENT: Head: Normocephalic, hair thick and distributed throughout scalp Eyes: Conjunctiva clear, nonicteric, PERRLA, OEMs intact. Ears: Right ear; tympanic membrane intact with light reflex noted. Left ear;
tympanic membranes intact, red and bulging, no drainage noted in canal. Pinna/tragus w/o tenderness
bilaterally. Nose: Nares patent and unremarkable; Throat: Pharynx with clear drainage noted, tonsils 2/4
bilaterally. No loose teeth.; Neck: supple, lymphadenopathy noted in preauricular and posterior cervical
nodes, non-tender. Thyroid midline.
SKIN: not specified
CARDIOVASCULAR: not specified
RESPIRATORY: respirations unlabored
GASTROINTESTINAL: Abdomen sl. rounded with active bowel sounds, soft, non-tender, no masses or
organomegaly
GENITOURINARY: not specified
NEUROLOGICAL: not specified
MUSCULOSKELETAL: not specified
HEMATOLOGIC: not specified
LYMPHATICS: not specified
PSYCHIATRIC: not specified
ENDOCRINOLOGIC: not specified
ALLERGIES: NKD [Show Less]