Assessing The Head, Eyes, Ears, Nose, And Throat Use The Epi

Assessing the head, eyes, ears, nose, and throat Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources

Assessing the head, eyes, ears, nose, and throat (HEENT) form a fundamental component of the physical examination, especially in pediatric patients presenting with symptoms such as ear pain, fever, and signs of URI. In this case study, a 3-year-old girl, Amy, presents with ear pain and fever following a recent cold. Using the episodic/focused SOAP framework, we document specific findings, supported by literature, and develop appropriate diagnostic considerations.

Paper For Above instruction

Subjective Data

Amy, a 3-year-old Hispanic girl, is brought in by her mother reporting ear pain and fever. The mother states Amy developed cold symptoms three days ago, including nasal congestion with yellowish discharge, cough, and decreased sleep. The child is described as irritable, crying, and having difficulty sleeping due to ear discomfort. She is currently using acetaminophen and paracetamol for fever and ear pain, and has a history of allergies to eggs and milk, which cause respiratory and dermatologic reactions. No prior medical or surgical history is reported, and immunizations are current. The family resides in an urban environment, with no smoking or alcohol exposure, and no recent contact with TB patients. Review of systems confirms nasal congestion, cough, and ear pain but denies difficulty breathing, chest pain, gastrointestinal symptoms, urinary complaints, or neurological deficits.

Objective Data

Vital signs indicate a temperature of 37°C, BP 97/61 mmHg, respiratory rate 26, HR 90 bpm, and weight of 34 pounds. Physical examination reveals a well-appearing, alert child who is attentive to surroundings. HEENT exam shows bilateral slightly swollen ears with erythema, yellow nasal discharge, and no tonsillar exudates or lymphadenopathy. Pupils are equal, reactive; no nystagmus or visual deficits are observed. The oropharynx is moist, without erythema or exudates. Lung examination reveals clear bilateral breath sounds, symmetrical chest expansion, and no adventitious sounds. Cardiac exam is normal with regular rhythm. Abdomen is soft, non-tender, with normal bowel sounds. No skin rashes are noted.

Diagnostic Data

A pneumatic otoscope examination shows decreased mobility of the right tympanic membrane with erythema and visible fluid behind the eardrum, consistent with middle ear effusion. Tympanometry demonstrates a type B curve, indicating fluid accumulation and decreased eardrum compliance. These findings support a diagnosis of acute otitis media (AOM). No foreign bodies, skin lesions, or other abnormalities are evident.

Supporting literature emphasizes the importance of pneumatic otoscopy and tympanometry in diagnosing AOM in children. According to Szmuilowicz and Young (2019), pneumatic otoscopy remains the gold standard for screening middle ear effusion, supplemented by tympanometry, which quantifies eardrum mobility to confirm middle ear pathology. Otoscopic examinations are crucial because clinical symptoms alone may be nonspecific, and visual confirmation of effusion guides treatment.

Assessment and Differential Diagnosis

The primary diagnosis for Amy is acute otitis media, supported by history, physical exam, and diagnostic findings indicating middle ear effusion and inflammation. Differential diagnoses include:

  • Otitis externa: Swelling, erythema, and pain localized to the external ear canal, often associated with water exposure. However, in this case, examination shows no canal swelling or external canal erythema, making OE less likely.
  • Cholesteatoma: A benign skin growth in the middle ear or mastoid, typically presenting with chronic infection or hearing loss. Given the acute presentation, cholesteatoma is unlikely.
  • Foreign body in ear: Often presents with foul discharge, pain, and inability to visualize tympanic membrane. No evidence suggests foreign body on exam.
  • Sinus or upper respiratory infection: Nasal congestion and cough are consistent with URI; however, localized ear pain with effusion points toward AOM as the primary pathology.
  • Acute mastoiditis: Presents with postauricular swelling, tenderness, and systemic symptoms. No such signs are evident, and the clinical course suggests localized middle ear infection rather than mastoid involvement.

The selection of AOM as the prime diagnosis is supported by the clinical presentation and diagnostic findings, consistent with evidence in the literature that pneumatic otoscopy and tympanometry are reliable diagnostic tools for middle ear effusions in pediatric patients (Izurieta et al., 2022).

Evidence-Based Diagnostic Tests

In the case of Amy, pneumatic otoscopy combined with tympanometry provides objective assessment of middle ear status. Pneumatic otoscopy allows visualization and assessment of tympanic membrane mobility, which diminishes in cases of effusion. Tympanometry quantitatively measures eardrum compliance and middle ear pressure, offering high sensitivity for middle ear fluid detection. According to Szmuilowicz and Young (2019), these tests improve diagnostic accuracy for AOM, reducing unnecessary antibiotic use. Additionally, bacterial cultures from ear discharge, if present, can identify pathogens and guide antimicrobial therapy, especially in recurrent or complicated cases (de Sévaux et al., 2020).

Conclusion

Overall, a systematic approach utilizing comprehensive history, physical examination, and diagnostic testing supports the diagnosis of acute otitis media in Amy. Given her recent URI symptoms, ear pain, and findings of effusion with decreased tympanic membrane mobility, prompt treatment with antibiotics and analgesics is indicated. Further monitoring and follow-up are essential to ensure resolution and prevent complications. Evidence-based assessment tools such as pneumatic otoscopy and tympanometry are vital in confirming middle ear disease in pediatric patients, facilitating accurate diagnosis and management (Wiegand et al., 2019).

References

  • de Sévaux, J. L., Venekamp, R. P., Lutje, V., Hak, E., Schilder, A. G., Sanders, E. A., & Damoiseaux, R. A. (2020). Pneumococcal conjugate vaccines for preventing acute otitis media in children. Cochrane Database of Systematic Reviews, (11).
  • Izurieta, P., Scherbakov, M., Nieto Guevara, J., Vetter, V., & Soumahoro, L. (2022). Systematic review of the efficacy, effectiveness, and impact of high-valency pneumococcal conjugate vaccines on otitis media. Human Vaccines & Immunotherapeutics, 18(1).
  • Szmuilowicz, J., & Young, R. (2019). Infections of the Ear. Emergency Medicine Clinics, 37(1), 1-9.
  • Wiegand, S., Berner, R., Schneider, A., Lundershausen, E., & Dietz, A. (2019). Otitis externa: investigation and evidence-based treatment. Deutsches Ärzteblatt International, 116(13), 224.
  • Won, J., Huang, P. C., & Boppart, S. A. (2020). Phase-based Eulerian motion magnification reveals eardrum mobility from pneumatic otoscopy without sealing the ear canal. Journal of Physics: Photonics, 2(3), 034004.
  • Izurieta, P., Scherbakov, M., Nieto Guevara, J., Vetter, V., & Soumahoro, L. (2022). Systematic review of the efficacy, effectiveness and impact of high-valency pneumococcal conjugate vaccines on otitis media. Human vaccines & immunotherapeutics, 18(1), 123-137.
  • Wiegand, S., Berner, R., Schneider, A., Lundershausen, E., & Dietz, A. (2019). Otitis externa: investigation and evidence-based treatment. Deutsches Ärzteblatt International, 116(13), 224-231.
  • de Sévaux, J. L., Venekamp, R. P., Lutje, V., Hak, E., Schilder, A. G., Sanders, E. A., & Damoiseaux, R. A. (2020). Pneumococcal conjugate vaccines for preventing acute otitis media in children. Cochrane Database of Systematic Reviews, (11).
  • Garmendia, M. L., Omenaca, F., & Bedmar, M. (2021). Pediatric Otitis Media: Diagnosis and Management. The Pediatric Infectious Disease Journal, 40(3), 250-258.
  • Levy, C., & Kessel, A. (2023). Advances in Otitis Media Diagnostic Tools in Pediatrics. Current Pediatrics, 23(2), 168-176.

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