NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
INITIAL POST
Patient’s Initials: JS Age 11 Gender: Male
SUBJECTIVE DATA: (Given
... [Show More] by patient and patient’s grandmother)
Chief Complaint: Mild earache in right ear.
History of Present Illness:
James presents to the clinic today with complaints of a mild earache located in his right ear. He states that it has been going on for 2 days now and has not experienced any earaches in the past. James states that his ear pain is mild most of the time but becomes more severe when he is laying down to go to sleep. He states that he has a hard hearing from the right ear since the earache has stared but could hear out of it just fine before. His grandmother states that he has been taking Tylenol for the pain which has helped but she is concerned that it isn’t getting any better. James confirmed that the Tylenol does help alleviate the pain and rates his discomfort level medium.
Medications:
1). Tylenol 160 mg chewable tab, 3 tabs every 4 hours as needed for pain
Allergies: No known allergies, drug, food, or environmental.
Past Medical History:
1). No overnight hospitalizations. No chronic health issues. 2). Emergency room visit for right distal radial fracture
Past Surgical History (PSH)
1). Closed reduction of right distal radial fracture 2011
Personal/Social History:
Patient denies smoking, ETOH or illicit drug use. Patient enjoys being active and playing sports. Generally eats healthy foods, and does not eat out at fast food restaurants often. Typically has dinner at home with his family. Eats breakfast and lunch at home except during school when he takes a packed lunch. Doesn’t like a lot of vegetables but enjoys many fruits. Does not drink a lot of soda but does have some occasionally.
Immunization History:
Immunization are up-to-date and patient received his flu shot in September.
Significant Family History:
Father (alive) and paternal grandmother (alive) both have hypertension. Paternal grandfather (deceased at age 67) had type II diabetes and leukemia.
Lifestyle:
He is in 5th grade attending school at the local elementary and receives good grades.
Patient is active with soccer and basketball. Lives with both of his parents and 13 year old sister. His grandmother takes care of him when needed after school and during summer vacation.
Father works as a fisheries biologist and mother works part time as an aerobics instructor. No smokers at home. Grandmother lives on a lake and James spends a lot of time in the water during the summer months. He sees a dentist regularly and visits the pediatrician for yearly well visits.
REVIEW OF SYSTEMS:
General: Negative for fatigue. No fever, chills or night sweats. Negative for weight loss, palpitations, dyspnea, change in appetite, n/v, syncope, numbness/tingling. No asthma or h/o albuterol use.
HEENT: No changes in vision, does not wear glasses. Denies headaches. Reports not being able to hear well out of right ear for two days. Reports tenderness around the opening of the right ear canal. Denies discharge from ears. Denies history of excessive ear wax. Reports occasional use of cotton swabs in ears and denies any trauma associated with use. Denies history of seasonal allergies or ear infections. Denies exposure to loud music. Reports sense of smell is intact, denies dental caries or mouth pain. Reports no difficulty chewing or swallowing.
Neck: Denies injury or pain.
Breasts: Denies history of lesions, rashes, or changes in breasts.
Respiratory: Denies cough or sputum production. No dyspnea on exertion.
CV: No history of murmur. Denies chest discomfort or palpitations. No edema.
GI: Denies nausea or vomiting. No abdominal pain. + for occasional constipation and uses prune or apple juice to resolve. Denies acid reflux.
GU: Denies changes in urinary pattern. No incontinence or bed wetting. Denies being sexually active.
MS: Denies limitation in range of motion. + history of right wrist fracture. Denies any other trauma.
Psychiatric: No history of depression or anxiety. No suicidal or homicidal ideations. Denies sleep disturbances until recent earache which makes it difficult to fall asleep. Denies mental health history.
Neurological: Alert and oriented x 3, denies seizures, headaches, head trauma. No dizziness or gait disturbances.
Integumentary/Heme: Denies dermatitis, eczema, or psoriasis. Denies history of rash or serious bruising. + for occasional bruises associated with riding a bike or playing sports. Denies bleeding disorders or history of blood transfusion.
Endocrine: Denies juvenile diabetes, denies hormone replacement therapy. No endocrine symptoms.
Allergic/Immunologic: Denies history or symptoms of seasonal allergies. Denies allergies to drugs or food. No known immune deficiencies.
OBJECTIVE:
PHYSICAL EXAM:
Vital signs: T 98., RR 18, HR 84, BP 116/74, SpO2 99%, Wt 79 lbs, Ht 4’5”
General: A&O, well nourished, no acute distress.
HEENT: PERRLA, sclera white, conjunctiva pink. Ears: clean canals bilaterally, left tympanic membrane pearly grey with +light reflex and visible bony landmarks. Right tympanic membrane mildly inflamed presenting with erythema, edema, and narrowing of the external auditory canal. No purulent drainage observed. Pain upon palpation of the tragus and application of traction to the pinna No pain to palpation of mastoid bone. Difficulty hearing in right ear.
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]