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Amy Case Study

Name

Institution

Course

Professor's Name

Date

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Assessment of head, Neck, Eyes, Ears, Nose, and Throat

Patient Information

Age: 3 years

Sex: Female

Race: Hispanic

SUBJECTIVE DATA

Chief Complaint (CC): "Amy's ear hurts, and she has a fever."

History of Present Illness (HPI): Amy, a three-year-old girl with a fever and an aching ear,

was taken to the clinic by her mother. Developed cold 3 days ago with sniffles, yellowish

nasal discharge, and coughing. Her mother claims she started experiencing sniffles and a

"cold" three days ago. She can't sleep because of the fever and sobs whenever her ear hurts.

Medications:

Acetaminophen 10ml after meal twice per day

Amoxicillin for ear infection

Paracetamol 5 grams before bed and in the morning

Multivitamins every day containing vitamins A, C, and D

The diagnosis being treated, together with any particular symptoms or problems that the

medicine is meant to alleviate, are the reasons why the patient is taking the medication.

Allergies:

The patient is allergic to eggs and milk.

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The eggs cause difficulty breathing to the patient and rashes. The milk is causing the patient

to sweat a lot and itching.

Past Medical History:

No past medical history

To help identify the source of the child's symptoms and immediate treatment, the provider

could request additional tests like a throat culture, ear culture, or laboratory tests based on the

data acquired during the history and physical examination. If an infection is detected,

treatment options may include antibiotics, over-the-counter painkillers to treat fever and

earache, or decongestants to treat nasal congestion.

Past Surgical History (PSH):

No past surgical history

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

The three-year-old youngster resides in a downtown apartment with her parents,

grandparents, and other family members. There, people hydrate themselves using the local

water supply. No one in the family has ever smoked or consumed alcohol. The patient is not

in contact with TB sufferers.

Health Maintenance:

The patient does not consume fast food because no one in her family does. The patient

consumes a balanced and nutritious diet. Her parents' health insurance protects the patient.

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The patient does not consume fast food because no one in her family does. The patient

consumes a balanced and nutritious diet.

Immunization History:

The patient has had all the immunizations since she was a child.

Significant Family History:

Paternal grandmother: alive, 60 years, high blood pressure

Paternal grandfather: dead, 65 years, heart disease

Maternal grandmother: deceased, 58 years, hypertension

Maternal grandfather: alive, 62 years, mild asthma

Father: alive and healthy

Mother: alive and healthy but is allergic to dust particles.

Review of Systems

General:

The patient is in good health, but according to her mother, her child has a fever and a

cough. The mother disputes any weakening or weight loss in the kid.

HEENT:

The mother disputes any head bumps, bruises, or discharge from the eyes. The mother

disputes that the infant has yellow sclerae, double vision, or visual loss. She denies having a

sore throat, runny nose, congestion, or hearing loss. Nose, throat, and ears. The mother

acknowledges that the child's ears hurt. The child does not have trouble swallowing, and the

mother acknowledges that there is nasal discharge.

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Respiratory:

According to the mother, her child has a dry cough. The mother disputes having

trouble breathing.

Cardiovascular/Peripheral Vascular:

The mother disclaims experiencing chest pain, breathing difficulties, or dizziness.

Denies feeling pressure or discomfort in the chest. No edema or palpitations.

Gastrointestinal:

The mother denies experiencing diarrhea, vomiting, nausea, or stool changes. Denial

of anorexia. Neither blood nor abdominal pain.

Genitourinary:

The mother says she feels burning when she urinates but denies having vaginal

discharge.

Musculoskeletal:

The mother denies experiencing muscle weakness, stiffness, or back pain.

Neurological:

The mother denies experiencing trauma or numbness. Denies experiencing headaches,

vertigo, syncope, paralysis, ataxia, or tingling or numbness in the extremities. No

modification to bladder or bowel control.

Psychiatric:

The mother disputes that she has a mental illness. Denies a past filled with worry or

depression.

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Skin/hair/nails:

The mother denies experiencing hair loss, nail discolouration, skin rash, or itching.

OBJECTIVE DATA

Physical Exam

Vital signs: BP 97/61mmHg, temperature 37 degrees Celsius, height 40cm, weight 34

pounds, respiratory rate of 26 breaths per minute, and a pulse rate of 90 beats per minute.

General: The patient was stable, but she kept complaining of the ear pin, and the fever kept

increasing. The patient seems to be well-fed and physically mature. They are attentive and

time, place, and person-oriented.

HEENT: The patient has no nodules on the throat, no tumors or traumas on the head, equal

pupils, slightly swollen ears, and yellowish nasal discharge, and slightly swollen ears.

Neck: The neck has a wide range of motion. Its neck is flexible and lymphadenopathy-free.

The thyroid gland is mobile and not swollen.

Chest/Lungs: There are no wheezes, yet the chest is cloudy. There is no indication of

respiratory distress, and the chest appears symmetrical. The midline defines the trachea.

There are equal and distinct bilateral breath sounds.

Heart/Peripheral Vascular: Normal heart rate, no gallops or murmurs. Precordium is

peaceful. The fifth intercostal gap along the midclavicular line is where the point of

maximum impulse (PMI) is situated. There are no murmurs and steady heartbeats.

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Abdomen: There were no stomach rashes or palpitations. Soft, not sensitive, and not swollen

describe the abdomen. There exist and are expected bowel sounds. Organomegaly or

discomfort is absent.

Genital/Rectal: The patient's genitalia is not swollen at all. The results of the rectal

examination are normal. There is no enlargement or discomfort of the prostate gland.

Musculoskeletal: There are no assistive gadgets used by the patient. The results of the

musculoskeletal examination are normal. All joints have a complete range of motion, and

probing doesn't reveal any pain.

Neurological: Normal sensory and motor neurons were observed

Skin: No skin lesions, edema, or rashes were visible. Dry and warm skin is present.

Overall, the physical examination is consistent with the patient's CC, HPI, and history and is

within normal limits.

Diagnostic Results

Pneumatic Otoscope

A tool used in medicine to examine the ear is a pneumatic otoscope. This is the

primary method used by doctors to identify ear infections (Won, Huang, & Boppart, 2020).

The eardrum is collapsed using a pneumatic bulb, a light source, and a magnification lens. A

doctor can use this instrument to inspect the ear canal and check for effusions beneath the

tympanic membrane. Using the pneumatic otoscope, the doctor gently blows air on the

eardrum. Using the pneumatic bulb, the medical professional can gently press on the eardrum

to check for inflammation or injury to the eardrum and to see if there is fluid in the middle

ear (Szmuilowicz & Young, 2019). The eardrum would normally flutter in response to this

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airburst. If the fluid has accumulated in the middle ear, the membrane will move very little or

not at all, as observed by the doctor. Positive outcomes were achieved.

Tympanometry

Tympanometry is a diagnostic procedure that gauges how the eardrum (also known as

the tympanic membrane) moves in response to variations in air pressure. It can assess how

well the middle ear is working and look for issues, including fluid buildup, a ruptured

eardrum, or anomalies in the middle ear bones. The test aims to assess eardrum mobility. The

eardrum is moved due to sealing up the ear canal and adjusting air pressure (Szmuilowicz &

Young, 2019). The instrument inadvertently detects middle ear pressure by monitoring the

degree of eardrum mobility. A tiny probe is inserted into the ear canal during the test. The

eardrum's movement is recorded in response to a series of air pressure pulses generated by

the probe. The test findings are displayed on a graph known as a tympanogram, which can

assist the medical professional in identifying middle ear issues. In this instance, the outcomes

are favorable.

ASSESSMENT

Differential Diagnosis

Acute otitis media

Acute otitis media (AOM) is an ear infection that affects the middle ear. It is a common

disorder frequently brought on by bacteria or viruses, especially in young infants.

Acetaminophen and ibuprofen are two over-the-counter pain relievers that can be used to help

manage discomfort. In some circumstances, the medical professional could advise utilizing

ear drops to lessen ear swelling and irritation. This is a severe ear infection that hurts badly. It

is brought on by swelling and infection in the middle ear, which is the area directly behind

the eardrum (Izurieta et al., 2022). Despite being more common in infants and young

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children, AOM can affect anyone at any age. The risk of long-term issues like hearing loss

and developmental delay rises in school-age children who experience the same occurrence

repeatedly.

AOM symptoms include ear pain, fever, hearing loss, and ear discharge. Fever, malaise,

and pain are typical symptoms of this condition. Antibiotics are typically used to treat AOM

to eradicate bacterial infection (de Sévaux et al., 2020). The pain signals in young children

can be challenging to read. Still, some typical behaviors include touching or clutching the

hurt ear, becoming agitated or uninterested in eating or even vomiting. Acute otitis media

resolves independently within 24 hours and usually within three days. Since his symptoms

are consistent with acute otitis media, this child is diagnosed with the condition (Izurieta et

al., 2022). By observing how the eardrum responds to variations in air pressure,

tympanometry can be used to diagnose AOM. The test may reveal diminished eardrum

movement, indicating fluid or inflammation in the middle ear. A physical examination of the

ear and a sample of any ear discharge are two more procedures that may be performed to

identify AOM.

Cholesteatoma

The middle ear and eardrum can develop benign (noncancerous) skin growths called

cholesteatomas. It develops when abnormal skin cell growth and shedding into the middle ear

result in a mass of skin that can harm the nearby bones and tissues. Cholesteatomas can

happen to anyone at any age, but children and young adults are the most likely to develop

them. Chronic ear infections, eustachian tube dysfunction, and structural abnormalities of the

ear are just a few of the causes. The migration of skin cells from the external ear canal

through a perforation that results in chronically negative middle ear pressure leads to the

formation. After establishing themselves in the middle ear, the cells desquamate to create the

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cholesteatoma. If untreated, this condition will continue to erode medially and impinge on

intracranial structures, posing a life-threatening risk. Congenital cholesteatomas are another

possibility. This condition does not exist because most symptoms do not fit it, but it needs to

be closely monitored.

Otitis external

An infection of the outer ear canal is called otitis externa. Because of cuts, scratches,

or other breaks in the skin lining the ear canal, bacteria, fungi, or other organisms enter the

ear canal and cause the condition. Otitis externa risk is increased by swimming and other

activities that involve getting water in the ear (Wiegand et al., 2019). This ear condition

causes swelling and pain in the exterior ear canal, the tube that connects the eardrum to the

outer ear. Due to repeated exposure to water, which over time increases the ear canal's

susceptibility to inflammation, this condition is also known as a swimmer's ear.

Temporary hearing loss, ear discharge, itchiness in the ear canal, and ear pain are all

symptoms. Additionally, the infection may impair hearing and give the ear a pressure or

fullness sensation (Wiegand et al., 2019). After receiving treatment, the symptoms may go

away in a few days. Typically, ear drops containing antibiotics or antifungal medication are

used to treat otitis externa. If the infection is severe, the doctor may advise taking oral

antibiotics or packing the ear with a medicated dressing. But some situations go on for weeks

or even longer. This condition is disregarded because it does not result in fever.

Foreign bodies

Foreign bodies can create foul-smelling ear drainage due to infection or an abscess

and are visible when the ear canal is examined. Numerous symptoms, such as ear pain,

trouble hearing, and foul-smelling ear drainage, can be brought on by foreign materials in the

ear canal. If bacteria or other germs are introduced into the ear canal due to the presence of a

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foreign body, an infection may also result. To avoid further issues, removing any suspected

foreign bodies is crucial as soon as possible. A healthcare professional can typically perform

this in an office environment, but in some circumstances, a referral to an ear, nose, and throat

specialist may be necessary. It's best to refrain from attempting to remove a foreign object by

yourself because you risk more harm to the ear. This appears to be the primary cause in this

instance. The patient's symptoms match the illness exactly.

Acute mastoiditis

An infection of the mastoid bone, a portion of the skull situated behind the ear, is

known as acute mastoiditis. It is a dangerous condition that could be fatal and must be treated

immediately with antibiotics. The small channels (mastoid air cells) present within the bone

can allow the infection to travel from the middle ear to the mastoid bone. The mastoid bone is

impacted by this severe ear infection (Cassano, Ciprandi, & Passali, 2020). An ear infection

is the cause of this disease. This illness needs a clear diagnosis. Since the internal ear and the

mastoid region are connected, acute infectious diseases of the internal ear frequently include

the mastoid area. Ear pain, fever, swelling and redness behind the ear, hearing loss, and acute

mastoiditis are all possible symptoms. Additionally, the infection may result in ear discharge

and changes to the ear's appearance. However, this diagnosis is disregarded because it does

not match the patient's symptoms.

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References

Cassano, P., Ciprandi, G., & Passali, D. (2020). Acute mastoiditis in children. Acta Bio

Medica: Atenei Parmensis, 91(Suppl 1), 54.

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), 2013693.

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.