Case Study For Pain In The Right Ear Assignment

Case Study For Pain In The Right Ear Assignment

Subjective Data

Chief complaint: pain in the right ear

History of presenting illness: James is an 11-years old male accompanied to the clinic due to pain in the right ear. The pain is mild, of acute onset, and does not radiate. The timing of the pain is at night when lying in bed and makes it hard to sleep. The patient states that the pain started after swimming during the summer season. The associating symptoms are increased local temperature in the same ear, fever, headache, and loss of hearing. However, he denies otorrhea, running nose, eye ache, blurring of vision, and throat pain Case Study For Pain In The Right Ear Assignment.

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Current medication: cetirizine 5mg PRN for allergies

Allergies: the patient is allergic to dust and cold weather by sneezing and generalized itchiness when he gets in contact. He relieves by taking cetirizine. The patient denies food and drug allergy.

Past medical history: the patient denies chronic medical illness, hospitalization, and blood transfusion.

Surgical history: the patient denies minor and major surgical procedures

Immunization: his immunization schedule is up to date. His last tetanus vaccine was three months ago.

Social history: the patient is a grade five student. He lives with his grandmother and uncle. He is academically bright and actively participates in sports like swimming and basketball. He denies the use of alcohol and smoking.

Family history: James is the firstborn in a family of two children. His parents are alive and healthy, with no record of chronic diseases. His younger sister is four years and has asthma. His paternal grandmother has had asthma since childhood. His paternal grandfather died due to COPD Case Study For Pain In The Right Ear Assignment.

Review of system

General: the patient dies of malaise, weight loss, and sweating.

Skin: the patient denies skin rash, itchiness, and peeling.

Respiratory system: the patient denies coughing, chest pain, wheezing, and sputum production

Cardiovascular: the patient denies chest pain, palpitations, syncope, dyspnea, and tachycardia.

Gastrointestinal system: the patient demies abdominal pain, diarrhea, vomiting, nausea, constipation, and reflux.

Genitourinary system: the patient denies hematuria, dysuria, polyuria, and oliguria.

Neurological: the patient denies facial drooping, numbness, tingling sensation, and muscles weakness.

Musculoskeletal: the patient denies joint pain, stiffness, muscle pain, and muscle spasms.

Hematological: the patient denies anemia, fatigue, bleeding tendencies, and easy bruising.

Lymphatics: the patient denies lower limb swelling, enlarged lymph nodes, and enlarged lymph nodes.

Endocrine: the patient denies heat and cold intolerance, polydipsia, polyuria, striae, and itchiness.

Allergies: the patient develops hives, sneezes, and itches, when exposed to cold and dust.

Objective Data

General: the child is calm and oriented. He has no pallor, jaundice, cyanosis, edema, lymphadenopathy, or dehydration.

Vitals: the temperature at 37.8, blood pressure at 101/61mmHg, the pulse rate at 68beats per minute, and oxygen saturation at 98% room air.

HEENT: the head is round and atraumatic. The external ear is prominent and swollen. The eustachian is erythematous and bulging. However, there is no ear discharge, vesicles at the Eustachian tube, and perforation of the eardrum. The eyes are pink and moist. The nose is moist with no erythema and posts nasal drip.

Respiratory system: the chest has symmetrical movements during respiration. The clung fields are clear with vesicular breath sounds.

Cardiovascular system: the heart sounds S1 S2 is present with no added sounds and murmurs. The peripheral pulse is present at a normal volume with a regular rate and rhythm.

Abdominal examination: the abdomen is round with no mass and scars. The bowel sounds are present. There is a tympanic percussion note. There is no tenderness and organ enlargement.

Diagnostic investigations: Tympanometry to measure the pressure changes in the inner ear. Ear radiograph and head CT scan rules out anatomic deformities in the ear. Pneumatic otoscopy is the standard examination technique that checks the external ear and tympanic membrane for color change, position, mobility, and perforation Case Study For Pain In The Right Ear Assignment.

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Assessment

Differential Diagnoses

Acute otitis media
Otitis externa
Ear foreign body
Chronic otitis media
Bullous myringitis

Primary diagnosis

Acute otitis media: is a common pediatric emergency associated with inflammation of the ear drum. The etiology of the inflammation can be trauma or infection by bacteria, fungi, or viruses. The presenting complaints in otitis media are otalgia, fever, recent onset of anorexia, and headache. The inflammation causes the bulging of the tympanic membranes, erythema, and opacity. According to the American pediatrics association, the etiology of otitis medical is classified into host factors, infectious factors, allergic factors, and environmental factors. Factors related to allergies are allergic rhinitis. Environmental factors are passive smoke exposure and infant feeding methods. Infectious factors include viral and bacterial pathogens (Vanneste, P., & Page, C. 2019). The host factors are the immune system, anatomic structures, and genetic predisposition. This is the primary diagnosis because the patient presents with similar symptoms. Additionally, he has allergic and environmental factors that cause otitis media. However, diagnostic tests like cultures and sensitivity determine the pathogenicity of the inflammation.

Differential diagnoses

Otitis externa: is the inflammation of the external auditory canal. It presents with otalgia, hearing loss, tinnitus, fever, itching, ear discharge, cellulitis of the face or neck, and ear fullness. It is common in patients with a history of ear trauma, high humidity, water retention during cleaning, increased temperature, and exposure to activities of water like swimming (González, et al, 2021)Case Study For Pain In The Right Ear Assignment. Patients with allergic conditions like allergic rhinitis, asthma, and asthma have a higher risk of otitis externa. The patient has a history of swimming during the summer period and has allergic rhinitis, thus increasing the risk for otitis externa. However, it is not the actual diagnosis because the patient has no symptoms of facial swelling, lymphadenopathy, itching, cellulitis of the face, and discharge.
Foreign body in ear: is a common pediatric emergency presenting with pain in the ear canal, significant discomfort when sleeping, and hearing loss. A foreign object causes inflammation of the ear canal increasing the risk for bacterial infection, which presents with a sense of fullness, erythema, and foul-smelling discharge (Lou, Z. 2021). The entry of a foreign body n the ear could be during cleaning, swimming, or an insect flying into the ear. The patient presents with similar symptoms; ear pain and loss of hearing but is it not the actual diagnosis because he has no ear discharge.
Chronic otitis media: is the perforation of the tympanic membrane with or without discharge at the middle ear. It presents with mild to moderate otalgia, hearing loss, fever, vertigo, and discharge. Chronic otitis media persists from acute otitis media causing perforation of the ear drum. It may cause facial paralysis and meningitis. This is not the patient’s diagnosis because he denies of discharge and vertigo. On examination, the tympanic membrane was intact.
Bullous myringitis: is the infection of the ear characterized with vesicles at the tympanic membrane. The etiology of the infection is from bacteria and viruses (Chung, et al, 2018). It presents with acute ear pain that is sharp and throbbing. It occurs together with upper respiratory tract infections. This is not the patient diagnosis because he has no blisters in the tympanic membrane. Additionally, the patient presents with mild pain on one ear.

References

Chung, J., Lee, D. Y., & Kim, Y. H. (2018). Management of myringitis: Current concepts and review. The Laryngoscope, 128(9), 2157-2162. https://doi.org/10.1002/lary.27179

González, J. L. T., Suárez, L. L. R., & de León, J. E. H. (2021). Malignant otitis externa: an updated review. American Journal of Otolaryngology, 42(2), 102894. Case Study For Pain In The Right Ear Assignment

https://doi.org/10.1016/j.amjoto.2020.102894

Lou, Z. (2021). The outcome and complication of endoscopic removal of pediatric ear foreign body. International Journal of Pediatric Otorhinolaryngology, 146, 110753.

https://doi.org/10.1016/j.ijporl.2021.110753

Vanneste, P., & Page, C. (2019). Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review. Journal of otology, 14(2), 33-39.

https://doi.org/10.1016/j.joto.2019.01.005