PRAC 6531 WEEK 3 Episodic Visit: HEENT Focused Note

Episodic/FocusNote Template

Patient Information:

Initials: L.W

Age: 6 years

Sex: Female

Race: African American

S.

CC (chief complaint): “Ear pulling.”

HPI: L.W. is a 6-year-old AA girl whose parents brought her for assessment and treatment. They presented with a chief complaint of their child pulling her right ear and being irritable. The symptoms began three days ago and have been worsening. They also reported that she had rhinorrhea, low-grade fever, changes in appetite, and was crying.

Current Medications: Daily Omega-3 supplements.

Allergies: No food or drug allergies.

PMHx: Immunization is not up to date. The last flu vaccine was two years ago. No current chronic illnesses or frequent infections. No history of surgery.

Soc Hx: L.W. is the second-born in a family of two. She lives with both her parents and her elder brother, who is ten years old. She is in first grade and enjoys school, including playing with her classmates. She has friends both at school and at home. She enjoys painting and swimming. Her parents report limiting screen time to five hours per day.

Fam Hx: The maternal great-grandfather died from COPD and HTN at 80 years old. The paternal grandfather has HTN and a history of stroke. The parents and siblings have no chronic illnesses.

ROS:

GENERAL: Positive for irritability, low-grade fever, and reduced appetite.

HEENT: Eyes: Denies visual changes or eye pain. Ears, Nose, Throat: Positive for right ear pulling and rhinorrhea. Denies nasal congestion or sore throat.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, SOB, or palpitations.

RESPIRATORY: Denies cough, sputum, or wheezing.

GASTROINTESTINAL: Reports loss of appetite. Denies nausea, vomiting, abdominal pain, or diarrhea.

GENITOURINARY: Denies dysuria.

NEUROLOGICAL: Denies headache, dizziness, or muscle weakness.

MUSCULOSKELETAL: Denies muscle or back pain.

HEMATOLOGIC: Denies bleeding or easy bruising.

LYMPHATICS: No swollen nodes.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: Denies excessive sweating, cold or heat intolerance, polyuria, or polydipsia.

ALLERGIES: No history of allergies.

O.

Physical exam:

Vitals: Wt-48 pounds, Temp-100.22F, HR- 98; SPO2 98% room air.

General: The child is pleasant, well-developed, active, and shows no distress.

HEENT: Head: Symmetrical and normocephalic. Eyes:  Ears: The right tympanic membrane is red and erythematous with a loss of light reflex. Nose: Presence of clear nasal drainage. Throat: Tonsillar glands are non-inflamed.

Diagnostic results: No tests were ordered.

A.

Differential Diagnoses

Primary diagnosis Acute Otitis Media, right ear (H66. 91): Acute Otitis Media (AOM) occurs when a microbe in the middle ear causes inflammation of the mucosa, causing swelling and irritation of ossicles in the middle ear and purulent inflammatory exudates (Jamal et al., 2022). This infection of the middle ear cavity is associated with ear pain and fever, which are the most distressing symptoms in children. Jamal et al. (2022) explain that AOM leads to irritability, sleeplessness, reduced appetite, imbalance, and dizziness in young children. AOM is the primary diagnosis based on the patient’s ear pulling, fever, irritability, appetite changes, and rhinorrhea. Positive exam findings include erythematous right tympanic membrane with loss of light reflex.

Otitis media with effusion (OME), right ear (H65. 91): OME is diagnosed in children with a hearing disorder, delayed acquisition of language, difficulties at school, and behavioral and sleep disorders (Vanneste & Page, 2019). The patient’s right ear pulling could be due to problems with hearing, making OME a differential diagnosis.

Acute otitis externa (AOE), right ear (H60. 531): AOE is an acute inflammatory reaction caused by a bacterial infection that affects the sub-dermis of the external auditory canal. Clinical features include severe ear pain aggravated by pressure on the tragus or tension on the pinna (Wiegand et al., 2019). Other symptoms are fever, otorrhea, itch, swelling, and erythema of the ear canal that can cause conductive hearing loss. AOE is a differential based on the patient’s ear pulling, often caused by ear pain, fever, and erythematous right tympanic membrane.

Rhinitis (J30. 9): This is characterized by inflammation of the nasal membranes. Clinical symptoms include sneezing, nasal congestion, nasal itching, and rhinorrhea (Liva et al., 2021). The patient has rhinorrhea, making this a differential diagnosis.

P.

Diagnostic studies: Pneumatic otoscopy to distinguish acute otitis media from otitis media with effusion (Chiappini et al., 2019).

Therapeutic Interventions: Cefdinir 250mg/5mL to treat otitis media (Chiappini et al., 2019).

Zyrtec 5 ml at night for rhinorrhea.

Patient Education: The parents were educated about the importance of the influenza vaccine. They were advised to bring the child back should the symptoms fail to improve. The parents were advised to encourage the child to have bed rest to restrict head movements that increase ear pain (Gaddey et al., 2019).

Referrals: Referral to an otolaryngologist if symptoms do not improve with treatment or if the child has recurrent infections.

Follow-up visits. Follow up after one week to assess treatment progress.

Reflection. I agree with the preceptor’s treatment of AOM with Cefdinir and Zyrtec. Cefdinir is an empiric antibiotic that is comprehensive and covers all likely pathogens causing AOM (Chiappini et al., 2019). I learned from the case that AOM diagnosis in children can be problematic because symptoms and indicators are not always conclusive, and physical examination can be challenging in this age group (Gaddey et al., 2019).In a different case, I would prescribe an analgesic and antipyretic for symptomatic management of ear pain and fever. Health promotion and disease prevention for this patient should focus on adhering to immunization. Pneumococcal vaccines have been found effective in decreasing the incidence of AOM in children. Thus, the parents should be educated on the importance of having the child undergo all vaccinations to reduce the incidence of future AOMs.

References

Chiappini, E., Ciarcià, M., Bortone, B., Doria, M., Becherucci, P., Marseglia, G. L., Motisi, M. A., de Martino, M., Galli, L., Licari, A., De Masi, S., Lubrano, R., Bettinelli, M., Vicini, C., Felisati, G., Villani, A., Marchisio, P., & Italian Panel for the Management of Acute Otitis Media in Children (2019). Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Diagnosis. The Pediatric Infectious Disease Journal, 38(12S Suppl), S3–S9. https://doi.org/10.1097/INF.0000000000002429

Gaddey, H. L., Wright, M. T., & Nelson, T. N. (2019). Otitis media: rapid evidence review. American Family Physician, 100(6), 350–356.

Jamal, A., Alsabea, A., Tarakmeh, M., & Safar, A. (2022). Etiology, Diagnosis, Complications, and Management of Acute Otitis Media in Children. Cureus, 14(8). doi: 10.7759/cureus.28019

Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of Rhinitis: Classification, Types, Pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183

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

Wiegand, S., Berner, R., Schneider, A., Lundershausen, E., & Dietz, A. (2019). Otitis Externa. Deutsches Arzteblatt international, 116(13), 224–234. https://doi.org/10.3238/arztebl.2019.0224