Patient Initials Alage, 12, Hispanic, Male, Insurance

Patient Initials Alage 12 Yorace Hispanicgender Maleinsurance

Patient initials: A.L. Age: 12 y/o Race: Hispanic Gender: Male Insurance: PPO

Information Source: Given by patient’s mother Allergies: NKA. Medication History: Tylenol 500 mg for pain or fever Family History: Mother Alive: 36 y/o / Healthy Father Alive: 45 y/o/ Healthy 1Sister Alive 16 Healthy Negative Hx for Cancer, Dead for CV event.

Past medical History (PMH): Negative for Chronic Disease. Unremarkable. Delivered at 39.2 W2D. Spontaneous vaginal delivery was uneventful. Normal birth weight, Apgar score 8/9. DC two days after delivery Immunization status: Up to date on all vaccines. : DTAP (5 doses); Hib (4 doses) IPV (4 doses); MMR (2dose); VAR (2 doses); HBV (3 doses); PCV (4 doses); RV (3 doses); HAV (2 doses); Influenza vaccine received on 12/19/2019 Developmental stage: Normal development according to his age.

Hospitalization: No previous hospitalization. History of mental illness/personality disorders: None. Physical trauma/falls: No reported during the last twelve months. Surgeries: No previous history Exercise: No engage in any regular exercise’s regimen/ only school sport activities (Hold now due to COVID 19 pandemic) Diet: Regular and well balanced.

Social History: Patient lives with his married parents in an apartment. Normal familiar dynamic, he has a healthy sister 16 y/o. He is a middle school student with good/normal development and social interaction Denied smoke, alcohol intake and use or recreational drugs. , No second-hand smoking exposure. Denies being sexually active Last annual physical exam: 12/19/2019 (Normal)

Subjective

Chief complaint: “My child has Left ear pain for 2 days"

History of present illness (HPI): A.L is an 12-year-old Hispanic male healthy patient, who came to the office today, complaining of left ear pain (rated 5-10) for two days as per her mother referred with the previous history of the patient started with an Upper Respiratory infection (URI) symptoms such as nasal secretion and nasal congestion seven days ago after the nasal discharge was yellow, little appetite and nausea in the child began to complain of earache that has been alleviated with drops of warm oil and today starts with a high fever that was treated with Tylenol, her mother notices the sleepy and malaise child, denies vomiting, dizziness or other symptoms

Review of Systems: Systemic: Patient complaint fever about 102.2. He denied change in appetite; tired, weakness or sleep disorder. HEENT. Head: Patient complaint left ear pain 5/ 10, No history of trauma, no complaining of headache. No sinus pain or any other facial pain is stated. Neck: Denies pain or stiffness. No swollen glands in the neck. Eyes: Denies blurring vision, double vision, redness or eye discharge. Oto-laryngeal : Complains left ear pain , yellow nose discharge and congestion , denies nasal bleeding. Denies bleeding gums. No hoarseness. last dental exam was 6 months ago, no cavities Cardiovascular : Denies chest pain, palpitation or edema on the lower extremities. Respiratory : Denies shortness of breath, cough or wheeze. No complaints of chest congestion. Gastrointestinal: Denied appetite problems. Denied abdominal pain, no food intolerances, no nausea or vomiting, no constipation. Last bowel movement: 07/20/2020 Genitourinary: Denies changes in urinary habits, normal urinary frequency. Denies history of kidney stones, flank pain, cloudy urine or bad smell, denies being sexually active. Musculoskeletal: Denied joint pain or stiffness. Neurological: Denied drowsiness, or focal weakness, no syncope, no seizures, no visual or speech disturbances, no impaired mobility, no memory deficit. Mental: No anxiety, no depression, no memory problems, denied trouble concentrating. Integumentary: Denies pruritus, bruises or rash.

Physical Exam

Vitals Signs: Temp (Axillary): 102.20F. BP-sitting L: 108/66 mmHg (BP cuff size: Regular). Pulse Rate-Sitting: 92 bpm. (Regular rhythm). RR: 18 per min. Height 4’6’’, Weight: 85lbs. BMI: 20.5 Kg/m2 (normal) 50 percentile. Oxygen Saturation: 99 %. Pain Scale/Rate: 5/10.

General appearance: Patient normal percentile according height and weight, properly dressed, speech clear and appropriate, cooperative to the interview, alert, oriented in place, person, time. Discomfort due to the pain is reflected in his face and posture. Well hydrated, well nourished Skin: Skin normal turgor, no bruises, and no changes in moles. No visible or palpable lesions or rashes, no cyanosis. Lymph nodes : Left periauricular adenitis, no palpable cervical, supraclavicular, axillary or inguinal nodes.

HEENT: Head: Normocephalic, normal face symmetry. Scalp with no lesions, no tenderness. Hair distribution according to his age. Temporomandibular joint full ROM without clicks or pain bilaterally. No frontal or maxillary sinus tenderness. Face: Symmetric facial expression, no deformities, tenderness to palpation over maxillary sinuses, no periorbital edema, no changes in color pigmentation, no involuntary movements. Eyes: EOMs intact. Brows and lashes normal configuration, no edema, White sclera, no lesions; PERRLA. Ears: Right ear with normal appearance, no erythema, tympanic membrane pearly grey, translucent with no bulging, no discharge. Left tympanic membrane erythematous and bulging with diminished bony landmarks. No purulent drainage observed. Painful to palpation of mastoid bone.

Nose: Bilateral nares patent pink coloration without rhinorrhea; no edema of the turbinate found. Septum midline Mouth: pink, moist mucous membranes. No missing or decayed teeth. Throat: Pink normal oropharynx erythematous, without tonsillar edema or exudate; uvula midline. Neck: Flexible; denied pain. Thyroid not visible or palpable. No carotid bruits and no jugular vein distention.

Chest/Lungs: Chest wall symmetrical, no use of accessory muscles note, breath sounds are clear, no wheezing, rhonchi, or crackle, no prolonged expiration noted in the upper/lower lung fields. No nipple discharges or abnormal lump noted, no axillary lymphadenopathies. Cardiovascular: S1 and S2 regular rate and rhythm with no splitting. Carotid with no bruits. No JVD. No thrills. No rubs. Peripheral pulses present in all extremities. Capillary refill less than 3 seconds. No edema. Abdomen: Skin without lesions, or rashes. Abdomen flat and symmetric with no lumps or bulges. Bowel sounds presents in the 4 quadrants. Percussion reveals tympany over all quadrants. No tenderness no guarding in any quadrant with palpation. No palpable masses or hepatosplenomegaly. Genitals/Urinary: Penis circumcised without lesions, urethral meatus normal location without discharge, testis and epididymis with normal size without masses, scrotum without lesions. Tanner Stage 2. Musculoskeletal: Normal passive and active ROM in upper and lower extremities. No focal deficit, no joint inflammation or deformities noted. Neurologic: Patient alert and oriented in person, time and place, cranial nerves II-XII intact. No focal motor or sensory deficits. Coordination, sensation, and reflexes are intact.

Assessment

Acute Otitis Media, Left Ear (H65.02): is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute Otitis media is usually a complication of Eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid (Domino et al., 2017). According to Burns (2017), accurate diagnosis is essential to reduce overtreatment and antibiotic resistance. Types include AOM, suppurative effusion, bullous myringitis, persistent AOM, and recurrent AOM. Family history often supports diagnosis. The exam findings include erythematous, bulging tympanic membrane with diminished light reflex, which was observed in the left ear. Differential diagnosis rules out diffuse otitis externa, mastoiditis, cholesteatoma, and otitis externa with effusion based on clinical presentation.

Diffuse otitis externa, caused by Pseudomonas aeruginosa or Staphylococcus aureus, was ruled out due to the absence of itching, discharge, or external canal inflammation. Mastoiditis signified by postauricular swelling, redness, or tenderness was not present. Cholesteatoma and other middle ear pathologies were also unlikely given examination findings. Therefore, the diagnosis confirms acute otitis media in the left ear presenting with typical symptoms and examination results.

Plan

No labs or diagnostic tests were ordered at this time. The pharmacologic treatment includes Amoxicillin 500 mg orally every 12 hours for 10 days, dosed at 90 mg/kg/day, aligned with guidelines for pediatric AOM. Acetaminophen 325 mg every 4-6 hours as needed for fever and pain, matching weight-based dosing (10-15 mg/kg), not exceeding 75 mg/kg/day. Non-pharmacologic measures involve increasing fluids, use of cold drinks and popsicles, and sponging to reduce fever (with prior acetaminophen administration).

Caregiver education emphasized avoiding Q-tip use, maintaining good nutrition and rest, proper antibiotic use, and administration technique, including ear drop placement. Additional suggestions include considering natural adjuncts such as xylitol, probiotics, herbal ear drops, and homeopathic interventions to reduce pain duration and bacterial resistance. The importance of vaccination, especially pneumococcal conjugate vaccine to prevent ear infections, was reinforced. Good hygiene practices like handwashing, avoiding sharing food/drinks and second-hand smoke exposure are crucial preventative measures.

Follow-up: No referral is needed currently. Monitoring is recommended after 48 hours; if symptoms worsen, persist despite treatment, or new symptoms develop, further evaluation will be necessary.

References

• Burns, G. (2017). Otitis media: diagnosis and management. Pediatric Clinics of North America, 24(5), 1207-1223.
• Domino, M.E., Baldor, R.G., Golding, G.P., & Stephens, C. (2017). Pediatric Otitis Media. UpToDate. Retrieved from https://www.uptodate.com
• Buttaro, T.M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Manual of Pediatric Nursing Skills. Elsevier.
• American Academy of Pediatrics Clinical Practice Guideline. (2013). Otitis media with effusion. Pediatrics, 131(3), e962-e999.
• Rosenfeld, R.M., et al. (2016). Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngology–Head and Neck Surgery, 154(1_suppl), S1–S41.
• Lehman, A., & Rosenfeld, R. (2017). The diagnosis and management of childhood otitis media. The Lancet, 388(10063), 2022-2032.
• American Academy of Family Physicians. (2018). Otitis Media in Children. Family Physician, 98(8), 515-526.
• Heikkinen, T., & Järvinen, A. (2017). The common cold. The Lancet, 377(9750), 341-350.
• Riley, D., & Willerslev-Olsen, C. (2019). Pediatric Otolaryngology. Springer.
• U.S. Centers for Disease Control and Prevention (CDC). (2022). Prevention and Control of Pneumococcal disease. CDC Guidelines.