Patient’s Information
JM, 11 Years, Male, Caucasian
Subjective Data(S)
CC : "My ear has been hurting for the past two days."
HPI: 11-year-old Caucasian boy.
Location : Right ear
Onset : 2 days ago
Character: Painful and achy
Associated signs and symptoms : pain particularly when laying on the right side
Timing: Painful all the time, day and night
Exacerbating/ relieving factors: Sleeping on the right side makes the pain worse, Ibuprofen relieves pain
Severity: 3.5/10 pain scale
Medications: Over-the-counter Ibruprofen 200 mg for pain management administered every eight hours
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Allergies : None
PMH: No previous hospitalization apart from birth, which was without complications.
PSH: No surgeries.
Personal/Social history and lifestyle : Lives with both parents as an only child and grandmother care for him when parents are at work. Lives in a suburban neighborhood with parents and maternal grandmother. The patient enjoys swimming among other outdoor activities. No exposure to second-hand smoke as a passive smoker. Sits at the backseat and always wears a seat belt. The family actively involved in the local church.
Immunization history : All immunizations are up-to-date.
Significant family history: Grandfather passed away in 2013 at the age of 63 from a heart attack, myocardial infarction.
ROV
General: No weight loss, fever, and weakness
HEENT : Eyes: No visual impairment, blurred vision or yellow sclerae
Ears, Nose, Throat: Pain and difficulty in hearing on the right ear for the past two days, no sneezing, running nose or sore throat.
Respiratory: No shortness of breath or cough
Cardiovascular : No chest pain or discomfort. No palpitations or edema.
Gastrointestinal: No anorexia, nausea, vomiting or diarrhea. No abdominal pain.
Genitourinary: No burning on urination
Musculoskeletal : No muscle or joint pain or stiffness.
Psychiatric: No history of depression.
Neurological: No headache, dizziness, numbness, paralysis, or any a particular tingling. Constant bowel and bladder control.
Skin: No rash or itching
Hematologic: No bleeding or anemia.
Endocrine: No reports of sweating or cold. No polyuria or polydipsia.
Allergic: No allergies. No history of asthma, eczema, or rhinitis.
Objective Data (O)
Physical Exam
EENT: Eyes are non-reddened.
Ears: Use of otoscope visualized external auditory canal, and middle ear shows mild redness and bulging with some fluid but no pearly white lesions — no drainage from the ear and no grimace during the examination. The patient is not pulling on the ear or showing any sign of distress.
Nose: No redness, drainage, or soreness. No sore throat.
Diagnostics Results
The patient is not feverish at 37.1
Hearing evaluation to check cranial nerve V111: Intact, able to hear a whispered voice.
Weber and Rinne tests: Weber on the left heard better, lateralization to the right. Rinne tests (positive) showed air heard longer, a slight difference to the right side (Ball, Dains, Flynn, Solomon, & Stewart, 2015) .
Pneumatic otoscopy Tympanogram: Used to check for otitis media with effusion
Generally, the patient's responses to recent ear issues indicated that he had spent the majority of his summer swimming and did hit the water on his right side hard severally. He admitted he rarely cleaned his ears although the mother helped from time to time. As far as both the patient and the grandmother can remember, there is no history of placing objects in the ear. Upon inquiry, the grandmother asserts that the patient was not breastfed and he used a pacifier. The patient reports that sounds are muffled on his right side, but he can generally hear okay. According to the patient, there is no ringing in the ear. The patient does not have to turn his head to listen and typically appears to have no evident severe hearing since he can repeat simple sentences promptly.
Assessment
Primary and differentials diagnosis
Middle Ear Effusion: There is a visualization of fluid and according to the Weber test; there is lateralization on the right side which can be associated with the obstructed ear (Ball, Dains, Flynn, Solomon, & Stewart, 2015) .
Acute Otitis Media: The patient's ear is reddened, and he reports pain, mainly when he sleeps on his right side. While the patient is not feverish and the symptoms are generally mild, there is a possibility of infection particularly because the patient has a risk factor of not being breastfed (Harmes, Blackwood, Burrows, Cookie, Harrison, & Passamani, 2013) .
Otitis media with effusion: The patient showcases symptoms of the condition through fluid visualization in the middle ear, redness and bulging and pain (Harmes, Blackwood, Burrows, Cookie, Harrison, & Passamani, 2013) .
Ear trauma: The patient reports to swimming majority of his summer, which might have resulted in blunt trauma when he hit the water since in most cases, it was the right side that took the hit. While perforation is not visualized, ear trauma is a presumptive diagnosis (Dains, Baumann, & Scheibel, 2016) .
Cholesteatoma: Cholesteatoma is associated with difficulty in hearing but no full loss of hearing. However, it is less likely since no perforation or lesions are evident during the examination.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination. St. Loius: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care. St.Loius: Elsevier Mosby.
Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cookie, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians , 435-440.
