Case Study For Patient With Fever And Pain In The Ears

Case Study For Patient With Fever And Pain In The Ears

Patient’s particulars
Name: Amy
Age: 3years
Gender: female
Ethnicity: American
Subjective Data
Chief complaint: fever and pain in the ears.
History of presenting illness: Amy is a three years old girl accompanied by her mother to the hospital due to fever and ear pain. The ear pain is of acute onset at the bilateral ears. The pain does not radiate and increases in frequency and intensity upon coughing and blowing the nose. The child reports having pain in the jaws, nasal congestion, yellowish nasal discharge, postnasal drip, fatigue, and a productive cough. She denies difficulties in breathing, ear discharge, and wheezing Case Study For Patient With Fever And Pain In The Ears.

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Past medical history: the child has a cold three days ago. She has a history of recurrent rhinitis. She denies hospitalization and blood transfusion. Her immunization schedule is up to date.
Surgical history: the patient denies having a minor and major surgical procedure.
Allergies: she denies food, environmental, and drug allergy,
Family history: she is the firstborn in a family of two. Her younger sister is six months and healthy. Her parents are alive with n record of chronic diseases. Her grandparents are healthy with no record of illness.
Social history: the child is jovial and playful. She follows instructions from her parents and playgroup friends.
Review Of Systems
Cardiovascular: the child denies palpitations, chest pain, syncope, and dyspnea.
Gastrointestinal system: the child denies abdominal pain, nausea, vomiting, diarrhea, and constipation.
Genital urinary system: the child denies hematuria, polyuria, dysuria, and flank pain.
Musculoskeletal system: the child denies joint pain, muscle pain, and muscle spasms.
Skin: she denies skin rash and itchiness,
Neurological: she denies paralysis, muscle weakness, and numbness of extremities.
Objective Data
General: the child is in fair general condition, calm, and oriented. She has no pallor, jaundice, or cyanosis.
Vitals: temperature is at 39.6 degrees Celcius, oxygen circulation at 99% room air, blood pressure at 90/68mmhg, and respiratory rate at 22 breaths per cycle.
HEENT: the child has purulent nasal and pharyngeal secretions, mucosa erythema, periorbital erythema, and facial erythema.
Diagnostic investigation: nasal cytology and nasal sinus biopsy are the recommended tests to rule out acute and recurrent sinusitis. Nasal cytology determines if the patient has nasal polyps, allergic rhinitis, and eosinophilia. Culture and sensitivity of the nasal secretions to rule out bacterial and viral sinusitis. CT scanning of the nose makes an accurate diagnosis of rhinosinusitis Case Study For Patient With Fever And Pain In The Ears.
Assessment
Differential diagnoses
1. Rhinosinusitis
2. Allergic rhinitis
3. Otitis media
Rhinosinusitis is the inflammation of the nasal cavity and extends to the paranasal sinuses with concurrent rhinitis. The presenting symptoms are coughing, pharyngeal irritation, nasal blockage, post-nasal discharge, facial pain, hyposmia, post-nasal discharge, redness of the nose, dental pain, fever, and ear pressure (Bachert, et al, 2021). These symptoms may persist for up to 10 days and worsen at the onset of an upper respiratory infection. This is the patient’s primary diagnosis because she presents with similar symptoms, she had a cold three days ago and has a history of recurrent rhinitis.
Allergic rhinitis is the inflammation of the nasal membranes proceeding exposure to an allergen. It presents with sneezing, itching eyes, nose, and ears, post nasal drip, anosmia, headache, tearing, earache, fatigue, drowsiness, and eye swelling (Zhang, et al, 2021). The common cause of allergic rhinitis is exposure to cold air and environmental allergens such as fur, dust, and pollen. The patient presents with almost similar symptoms but this is not the actual diagnosis because she denies environmental allergens.
Otitis media is the inflammation of the middle ear due to bacterial or viral infections or trauma. The risk factors are weak immune system, smoking, and cold. The presenting symptoms are earache, fever, fluid draining from the ears, loss of balance, hearing difficulties, and pulling at both ears (De Corso, et al, 2021)Case Study For Patient With Fever And Pain In The Ears. This is not the patient’s diagnosis because she has a stable balance and denies ear discharge.

References
Bachert, C., Bhattacharyya, N., Desrosiers, M., & Khan, A. H. (2021). Burden of disease in chronic rhinosinusitis with nasal polyps. Journal of asthma and allergy, 14, 127. https://doi.org/10.2147%2FJAA.S290424
De Corso, E., Cantone, E., Galli, J., Seccia, V., Lucidi, D., Di Cesare, T., … & Fetoni, A. R. (2021). Otitis media in children: Which phenotypes are most linked to allergy? A systematic review. Pediatric Allergy and Immunology, 32( 3), 524-534. https://doi.org/10.1111/pai.13431
Zhang, Y., Lan, F., & Zhang, L. (2021). Advances and highlights in allergic rhinitis. Allergy, 76(11), 3383-3389. https://doi.org/10.1111/all.15044 Case Study For Patient With Fever And Pain In The Ears

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male)Case Study For Patient With Fever And Pain In The Ears. You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance)Case Study For Patient With Fever And Pain In The Ears.

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: Denies weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat Case Study For Patient With Fever And Pain In The Ears.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Patient With Fever And Pain In The Ears

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

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This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting Case Study For Patient With Fever And Pain In The Ears