Nicole Schneider
Site Evaluation 1
Pediatrics – H&P 1
History
Identifying Data:
Name: TC
Sex: Male
Address: Staten Island, NY
Date of Birth: xx/xx/2018
Age: 4 years old
Date: 11/10/21, 9:30AM
Location: Premier Pediatrics, Staten Island NY
Race: Caucasian
Religion: Catholic
Source of Information: Self & Mom
Reliability: Reliable
Chief Complaint: “Right ear hurts” x 12 hours
HPI:
TC is a 4 year old male with no significant past medical history who presents accompanied by his mother for right ear pain x 12 hours. Mom reports she noticed the patient tugging at his right ear while putting him to sleep last night, and this morning patient woke up crying complaining his right ear hurts. Patient has been irritable with decreased appetite since this morning. Mother states patient has been feeling better since taking Tylenol 4 hours ago. Patient was evaluated at this office 1 week ago for cough and congestion, and RVP results were positive for enterovirus. Mom reports the patient still has a lingering wet cough and mild runny nose with clear discharge, but admits his congestion has been resolving since taking Bromfed DM and nebulized saline daily x 1 week. Mom reports patient gets 1-2 ear infections per year, last ear infection was > 1 year ago. Mom denies any recent fever, chills, drainage from the ear, noticeable redness or swelling to ear, left ear pain, sore throat, headaches, dizziness, facial pain, nausea, vomiting, abdominal pain, chest pain, shortness of breath, difficulty breathing, wheezing, recent travel, or sick contacts. Patient denies difficulty hearing.
Past Medical History:
Past/present illnesses – None
Immunizations – All vaccinations up to date.
Blood Transfusions – None.
Hospitalizations – None.
Past Surgical History:
None.
Medications:
Bromfed DM
Nebulized 0.9% Saline Solution
Allergies:
No known drug, food, or environmental allergies.
Family history:
Mother – 31, alive and well, no PMH.
Father – 36, alive and well, PMH of HTN.
Brother – 3 months, alive and well, no PMH.
Social History:
TC is a 4 year old male who attends preschool. Lives in Staten Island with his parents and brother. Mother is a social worker, father is a teacher.
Habits – Mother denies any smoking or alcohol use in the home.
Travel – Mother denies recent travel.
Safety – Child uses car seat with seatbelt.
Diet – Mother states patient has not been eating well since this morning, but typically eats a well-balanced diet.
Review of Systems:
General – Admits to loss of appetite. Denies fever, chills, night sweats, weight loss, or generalized weakness/fatigue.
Skin, Hair, Nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies head trauma.
Eyes – Denies itching, tearing, vision loss, or visual disturbances. Patient does not follow with any Ophthalmologist.
Ears – Admits to right ear pain x 24 hours. Denies changes is hearing, drainage from ear, blood from ear, trauma to ear, or recent swimming.
Nose/sinuses – Admits to mild runny nose with clear nasal discharge, and mild congestion x 1 week. Denies obstruction, nose bleeds, sinus pressure/pain, or purulent drainage.
Mouth/throat –Denies bleeding gums, sore tongue, sore throat, mouth ulcers.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
Pulmonary – Admits to mild wet cough x 1 week. Denies wheezing, difficulty breathing, coughing up blood, or blue discoloration.
Cardiovascular – Denies chest pain, shortness of breath, or loss of consciousness.
Gastrointestinal – Denies intolerance to specific foods, abdominal pain, nausea, vomiting, diarrhea, constipation, difficulty swallowing, heartburn, abnormal flatulence, jaundice, or blood in stool.
Nervous – Denies seizures, headache, loss of consciousness, imbalance, sensory/motor dysfunction, weakness, or change in cognition, mental status or memory.
Musculoskeletal – Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral Vascular – Denies swelling of arms or legs, or discolorations.
Hematological – Denies anemia, easy bruising or bleeding, or lymph node enlargement.
Endocrine – Denies increased drinking or eating, denies increased urination, heat or cold intolerance, or excessive sweating.
Differential Diagnosis
- Right acute otitis media
- Bilateral acute otitis media
- Right otitis externa
- Perforated TM
Physical Exam
Vital Signs
Temperature – 100.2 degrees F (tympanic)
BP – 106/62 (left arm, sitting)
RR – 22 breaths/minute (unlabored)
HR – 114 beats/minute (regular)
O2 Saturation – 100% (room air)
Weight – 31 lbs
Height – 37 inches
BMI – 15.9
General Appearance – Pt is sitting upright on exam bed, well-appearing, in no apparent distress, alert & oriented x 3. Pt appears to be well-nourished, has good posture, dressed appropriately, well-groomed with good hygiene, looks appropriately his stated age of 4 y/o.
Skin – Skin is warm and moist with good turgor. Skin is non-icteric with no rashes, erythema, discolorations, bruises, masses, or lesions.
Hair – Hair is average in quantity with even distribution and smooth in texture. No signs of seborrhea, lice, or nits.
Nails – Capillary refill < 2 seconds throughout. No clubbing or cyanosis.
Head – Atraumatic, normocephalic. Head is nontender to palpation, no bruises or swelling.
Eyes – Symmetrical OU, no signs of exophthalmos, ptosis, or strabismus. Sclera are white, conjunctiva are pink and clear. Full visual field intact. Pupils equal round and reactive to light. Extraocular movements intact.
Ears – Symmetrical and normal size. No evidence of external lesions, masses, or trauma. External ear canals are non-edematous and non-erythematous with no discharge or blood AU. +Right TM erythematous and bulging with mild effusion, no perforation. +Left TM mildly erythematous and bulging with no perforation. Auditory acuity intact AU.
Nose/Sinuses – Nasal mucosa moist with clear discharge from bilateral nares. Symmetrical with no obvious masses/polyps, lesions, deformities, epistaxis, or trauma. Septum midline without lesions, deformities, injection or perforation. No foreign bodies noted. Sinuses are nontender.
Mouth/Pharynx – +Pharynx is mildly erythematous with no lesions or exudates, uvula is pink and midline with no deviation, tonsils present with no swelling. +Clear postnasal drip noted in posterior pharynx. Lips are pink and moist, no cyanosis or lesions, non-tender to palpation. Palate pink and well-hydrated, no lesions, masses, or scars, non-tender to palpation. Palate rises symmetrically. Gingivae pink and moist. Tongue pink, well-papillated.
Neck – Thyroid nontender to palpation, no thyromegaly or bruits. No palpable lymph nodes.
Lungs – Clear to auscultation bilaterally, no audible wheezing, rhonchi, or stridor. Chest expansion and diaphragmatic excursion symmetrical.
Heart – Regular rate and rhythm. S1 and S2 noted, no murmurs, S3, S4, or friction rubs.
Abdomen – Symmetrical with normal contour. Abdomen is nondistended with no noticeable pulsatile masses, hernias, or scars. Bowel sounds normoactive throughout, tympanic throughout. Abdomen is nontender to palpation throughout.
Peripheral Vascular – No cyanosis or edema bilaterally. Peripheral pulses 2+ bilaterally.
Assessment:
TC is a 4 year old male with no PMHx who presents with mother for right ear pain x 12 hours. Pt has rhinorrhea, productive cough, and mild congestion since 1 week ago, and has been irritable with decreased appetite since ear pain began last night. On exam pt is febrile (T 100.2F), found to have bilateral acute otitis media and postnasal drip.
Diagnosis:
- Bilateral acute otitis media
- Postnasal drip
Plan:
#Bilateral Acute Otitis Media / Right ear pain
- Amoxicillin – 630 mg twice daily x 7 days (600 mL twice/day 3 teaspoons twice daily)
- Tylenol or Motrin PRN for pain/fever control
- Return to office in 1 week to recheck
- Return to office before 1 week with worsening ear pain, purulent drainage, bleeding, or high fevers
- Advise parent that child must stay home from school, and can return once 24 hours of being fever-free
#Postnasal drip / congestion
- Supportive care:
- Continue saline nebulizer
- Humidifier
- Bromfed DM PRN for cough (if pt develops cough)
- Educate parent that symptoms will likely continue to resolve, but to return to office if patient develops purulent nasal discharge, severe headaches, facial pain, or fevers.
