Patient information: PADDY 4-year-old Male Caucasian
S: SUBJECTIVE DATA
Chief Complaint (CC): “Paddy has had a cold for a few and been talking about
... [Show More] his ears popping and
feeling stuffy”. “He woke up this morning and said his ear really hurts too. He also feels warm to me”.
History of present illness (HPI):
O- Patient's mother stated he has had a cold for “a few” and the ear pain began this morning and he
“feels warm” as per mother. When did the cold symptoms begin? Did you take his temperature? When
did he start to feel warm? When did you start to feel your ears popping and feeling stuffy? When did the
ear pain begin?
L- Which ear feels popping and stuffy? Do both ears? Which ear hurts?
D- Woke up and said his ear hurts and has had a cold for “a few”. When did you start to feel the cold
symptoms? When do you think it started? How did the symptoms start? Have they been hurting ever
since you first felt the discomfort or does it come and go?
C- Popping and feeling stuffy with ear pain. Does the outside of your ear hurt? Does the inside of your
ear hurt? Does your throat hurt? Does your nose feel stuffy too? Have you been having difficulty
hearing? Do you feel like if you have water in your ear?
A- Does anything make you feel worse? Does anything make your ear ache worse?
R- Does anything relieve your symptoms?
T- Have you taken any medicine? Did your mom give you anything to make you feel better?
S- Using Wong-Baker visual scale from 1-10, 10 being the worst, what would you say your pain is at right
now? And what would you say your pain was at when you felt the ear start popping? Do you have any
nausea?
PMH: Full term NSVD twin gestation. 5lb 2oz at birth. No hospitalizations. NKDA. Chewable children’s
multivitamin with iron daily.
Family/Social History: Paddy lives with both parents, Mary and Patrick, and three siblings (Tommy is his
twin, and two older siblings). Paddy attends a half day K4 program and Mom states he is doing well and
likes going to school. Mary’s parents also live with the family and care for the children after school. They
have 2 dogs and a cat. Patrick and Mary’s father, John Foley both smoke, but not in the house.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: (-) Fever (+) Pain 3/5 Wong Baker Scale
HEENT: (-) Headache (-) Vision Changers (+) ear pain (+) popping ear feeling (+) stuffy ear feeling (+)
Stabbing pain in ear (-) Hearing loss (-) Ringing in ears (-) Nasal Congestion (-) Nasal discharge (-) Sore
Throat (-) Difficulty Swallowing
NECK/LYMPHATICS: (-) Enlarged lymph nodes [Show Less]