Discussion Week 5.docx
NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
INITIAL POST
Patient’s Initials: JS Age 11 Gender:
... [Show More] Male
SUBJECTIVE DATA: (Given by patient and patient’s grandmother)
Chief Complaint: Mild earache in right ear.
History of Present Illness:
Medications:
Allergies
Past Medical History:
Past Surgical History (PSH)
Personal/Social History:
Immunization History:
Significant Family History:
Lifestyle:
REVIEW OF SYSTEMS:
General
HEENT
Neck:
Breasts
Respiratory:
CV
GI:
GU:
MS:
Psychiatric:
Neurological:
Integumentary/Heme:
Endocrine:
Allergic/Immunologic:
OBJECTIVE:
PHYSICAL EXAM:
General:
HEENT:
Neck: Supple, no masses, 1cm palpable Right cervical lymph node, mobile nontender. Trachea midline.
CV: RRR, no murmurs or gallops. Normal S1 and S2.
Lungs: CTAB, no wheezing, rhonchi, rales: Clear to auscultation bilaterally; no wheezes, rhonchi, or rales. Chest symmetric
GI/GU: Soft, nontender, nondistended. Bowel sounds present in all 4 quadrants, no hepatosplenomegaly. No nausea or vomiting.
Musculoskeletal: No deficits observed. Full range of motion in all extremities.
Neuro: CN ll-Xll grossly intact. A&Ox3.
Skin: Skin largely intact. No bruises. A few bug bite on legs bilaterally. Scrap noted on right elbow. No dermatitis. No edema. Right ear slightly red.
Lab Tests:
None required.
Differential Diagnosis:
1). Otitis externa (swimmer’s ear)- Most likely the cause of the earache. Patient has been swimming a lot. Patient complains of increased pain when traction applied to pinna and palpitation of the tragus. Erythema, edema and narrowing of the external auditory canal are present. Right tympanic membrane mildly inflamed. Difficulty hearing with right ear. Tylenol alleviates the pain most of the time.
2). Ear canal trauma- Possible diagnosis due to inflammation of ear canal and presence of pain. Tylenol alleviates the pain most of the time. Trauma could have caused inflammation of the tympanic membrane.
3). Otitis media with effusion- Difficulty hearing in right ear which could be associated with conductive loss as middle ear fills with fluid. Discomfort or pain present.
4). Cerumen impaction- Difficulty hearing with right ear. Pain is associated with cerumen impaction. However, upon assessment with otoscope a buildup of ear wax should be seen.
5). Foreign body- Could be related to an insect or tip of cotton swab in ear. Possible diagnosis due to inflammation of ear canal and presence of pain. Trauma from the foreign body could be a source for the inflammation of the tympanic membrane. Foreign body in the ear can be associated with pain and trouble hearing.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Schaefer, P., & Baugh, R. F. (2012). Acute otitis externa: an update. American Family Physician, 86(11), 1055-1061. Retrieved from Walden Library databases. [Show Less]