which diagnosis would be accurate and why

which diagnosis would be accurate and why

APA format in a SOAP Note format.  1 page long with questions as to which diagnosis would be accurate and why.  I have included the references I need 3 peer review articles to be included

 

Patient Information:

Initials: JS  Age: 11   Sex: M  Race: Caucasian

SJ

CC: Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.

HPI: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear.  The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.

Current Medications:

1.  Ibuprofen 600mg PRN for earache pain

Allergies: NKA

PMHx: Up to date on all immunizations. No significant PMH.

Soc Hx: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer.

Fam Hx: Maternal grandmother died of a stroke at the age of 70. No other significant family history.

ROS:

GENERAL: No fever, fatigue or chills. No weight loss.

HEENT: Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears: Patient reporting pain in right ear and hearing loss. Nose, Throat:  No sneezing, congestion, runny nose or sore throat.

SKIN: No rashes or itching.

RESPIRATORY:  No shortness of breath, cough or sputum.

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

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

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing.

HEENT: PEERLA. Ears: Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact. Nose: Nose is patent without any rhinorrhea. Throat: Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012).

SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good.

RESPIRATORY: LS CTA bilaterally, no sternal retractions noted.

GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present.

NEUROLOGICAL: Cranial nerves II to XII are grossly intact w/out focal neurological defecits (Sullivan, 2012).

LYMPHATICS: No enlarged nodes.

ALLERGIES: No known allergies. No history of asthma, hives, eczema or rhinitis.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

Otoscopy: Otoscopy of the ear canal demonstrated erythema, swelling and there was difficulty visualizing the tympanic membrane as there was watery discharge present. According to Lieberthal (2013), otoscopy is usually sufficient enough to reach the diagnosis of  otitis externa in children, however, certain cases require additional diagnostics, especially when occurring in infants presenting with fever.

Labs: N/A

A.

Differential Diagnoses:

1.  Otitis externa – I chose this as the primary diagnosis because of the patient’s presenting symptoms and the context in which the patient experienced the symptoms. The patient complained of worsening ear pain and hearing loss in the right ear. The patient also reported that he had been swimming in the pool a lot recently. According to Wald (2018), otitis externa often occurs in children after swimming, causes pain and conductive hearing loss if pus or discharge is present and clinical findings include an erythematous, edematous ear canal and difficulty visualizing the tympanic membrane.

  1. Acute otitis media- Acute otitis media is another possible diagnosis for this patient because of his presenting symptoms. According to Thomas (2014), acute otitis media generally occurs in patients after a respiratory tract infection and symptoms can include fever, fatigue or malaise. Additionally, Thomas (2014) discusses how purulent discharge is usually present with a bulging tympanic membrane. However, the patient did not report respiratory tract infection related symptoms and was not febrile.
  2. Otitis media with effusion- Otitis media with effusion cannot be ruled out because there is often discomfort in the affected ear with conductive hearing loss, however, there is not usually any purulent fluid in the canal, nor is it associated with swimming (Thomas, 2014).
  3. Upper respiratory infection- upper respiratory infection is another possible diagnosis for this patient as it can cause blocking or painfulness in the ear as well as an erythematous tympanic membrane (Pettigrew, 2011). Additionally, upper respiratory infections often times precede otitis externa or other ear infections.
  4. Furunculosis- Furunculosis is another possible diagnosis for this patient. Furunculosis is

usually an infected hair follicle in the ear canal that leads to otalgia and tenderness of the

ear which this patient presented with. However it is not too likely as it usually affects the

cartilage of the year and does not lead to conductive hearing loss (Ibler, 2014).

References

Ibler, K., & Kromann, C. (2014). Recurrent furunculosis – challenges and management:

a review. Clinical, Cosmetic and Investigational Dermatology, 7, 59-64.

doi:10.2147/ccid.s35302

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson,

M. A.,  . . Tunkel, D. E. (2013). The diagnosis and management of acute otitis

media. Pediatrics, 131(3), 964-999. Retrieved September 25, 2018, from

http://pediatrics.aappublications.org/content/pediatrics/131/3/e964.full.pdf

Pettigrew, M. M., Gent, J. F., Pyles, R. B., Miller, A. L., Nokso-Koivisto, J., &

Chonmaitree, T. (2011). Viral-bacterial interactions and risk of acute otitis

media complicating upper respiratory tract infection. Journal of Clinical     

            Microbiology, 49(11), 3750-3755. doi:10.1128/jcm.01186-11

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F.

A. Davis.

Thomas, J. P., Berner, R., Zahnert, T., & Dazert, S. (2014). Acute Otitis Media—a

Structured Approach. Deutsches Ärzteblatt International, 111(9), 151-160.

Retrieved September 25, 2018, from

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