Pediatric Case Study Assignment Paper

Pediatric Case Study Assignment Paper

Pediatric Case Study Assignment Paper

1. What additional questions would you ask Annabelle and her mother today? –

I would ask Annabelle and her mother about the child’s history of exposure to tobacco smoke at home. Passive tobacco smoke exposure is a common environmental risk factor for Otitis media (Chiappini et al., 2019). I would also inquire about the history of similar ear infections and the seasons they mostly occur. OM is more prevalent during winter and early spring.

2. Do you agree with mom that 99.4 is a significant fever? Why or why not?

I do not agree with the child’s mother that 99.4 is significant because a low-grade fever is considered from temperatures of 99.6 to 100.3, which occur mostly in viral infections.

3. What will your focused physical exam include?

The focused physical exam will include a thorough exam of the head, eyes, ears, nose, and throat (HEENT). The ear exam will include a pneumatic otoscopy, which distinguishes acute otitis media from otitis media with effusion (Chiappini et al., 2019). The tympanic membrane will be assessed for color, position, mobility, and perforation during the examination.

4. When you look inside Annabelle’s right ear, you visualize what appears to be a piece of popcorn sitting in the outer two-thirds of the external auditory canal. The canal is red and has swelled slightly, but you can see around the kernel. TM appears gray. In deciding how to proceed, you think about your options. Should you irrigate the ear with water? Why or why not?

Ear irrigation should not be performed because it is contraindicated in removing foreign organic matter that can swell through osmosis and expand within the auditory canal. Organic matter and objects that can become friable and break into smaller evasive pieces are usually better extracted from the ear with suction than with forceps.

5. Prior to any type of procedure, you have the mother sign an informed consent for a procedure. What are the three major areas you must discuss when doing any type of procedure?

When seeking consent from the patient or the patient’s parent/guardian, the healthcare provider should discuss: The nature of the medical procedure, the potential risks and benefits of the procedure, and other alternatives, including their risks and benefits (Bazzano et al., 2021).

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6. When removing a popcorn kernel from her ear, you seat Annabelle with the affected ear facing you. She is quite calm and cooperative. You decide to use a curette to try to get behind the kernel to pull it out. Why is it important to keep a hand resting on her head while using the curette? 

The hand should continuously rest on the patient’s head to minimize the risk of scraping the external canal wall or perforating the tympanic membrane. A cooperative patient may move involuntarily due to a stimulated vagal nerve cough reflex. Thus, the provider’s hand should be stabilized by always remaining firmly in contact with the patient’s head (Michaudet & Malaty, 2018).

7. You remove the kernel from her ear! Since the EAC is quite swollen and red and somewhat abraded from the curette, what might you prescribe for her? Please list the directions as you would put them in a prescription.

Ciprofloxacin/Dexamethasone suspension. Put 4 drops in the right ear twice daily (morning and evening) for 5 days (Michaudet & Malaty, 2018).

8. What would be your post-procedure education?

The patient would be instructed to keep the ear dry for at least one week, especially if the tympanic membrane was perforated. The mother will be advised to administer the medication as directed and finish the prescribed dose to avoid an ear infection. Besides, the patient will be advised to seek immediate medical attention if she experiences worsening ear pain, ear discharge, headache, malaise, or elevated body temperature (Michaudet & Malaty, 2018). She will also be advised to refrain from inserting any objects in the ear, and ear cleaning with earbuds should be supervised.

References

Bazzano, L. A., Durant, J., & Brantley, P. R. (2021). A Modern History of Informed Consent and the Role of Key Information. The Ochsner Journal, 21(1), 81–85. https://doi.org/10.31486/toj.19.0105

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

Danishyar, A., & Ashurst, J. V. (2022). Acute Otitis Media. In StatPearls. StatPearls Publishing.

Michaudet, C., & Malaty, J. (2018). Cerumen impaction: diagnosis and management. American family physician, 98(8), 525-529.

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CASE STUDY /PROCEDURES: week 9
If information is not provided, make up or create the information in order to make your note complete. I should not see “unknown,” “information not given,” or “N/A” in your note! But you can put “none” if documented. For example, allergies -no allergies to medications.
For the SOAP note, you are expected to have an APA formatted title page, page numbers throughout, in-text citations, and references.
1. CASE STUDY for SOAP note : Follow template provided for SOAP note
*Patient Information: A. J. is a 9-year-old Hispanic female.
Subjective:
CC (chief complaint) Mother reported ”Annabelle’s nose started running 3 days ago and then last night she told me her right ear hurt so bad it woke her up.”
HPI: Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (9 year old Hispanic female). You must include the seven attributes of each principal symptom in paragraph form, not a list. Use the following info below to write the HPI in paragraph form:
Location: right ear
Onset: otalgia started last night, but rhinorrhea started 3 days ago.
Character: throbbing, pressure-like otalgia, clear nasal drainage
Associated signs and symptoms: clear rhinorrhea, low-grade fever, mild fatigue, decreased appetite, 2 loose stools started today, muffled hearing.
Timing: ear pain started last night while sleeping.
Exacerbating/ relieving factors: ear pain worsened when lying down on right side, Oral Tylenol provided some pain relief and reduced fever to 98.0
Severity: pressure-like ear pain at 6/10.

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed-
Soc Hx: include occupation (student) and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo questions here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death and age of any deceased first degree relatives should be included. Include parents, grandparents, and siblings.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
*GENERAL: Reports fatigue, low-grade fever, poor appetite. Denies night sweats.
HEENT: Head- Denies H/A, trauma, or dizziness. Eyes- Denies eye pain, blurry vision, diplopia. Ears- reports otalgia in the right ear, none in the left ear, reports muffled hearing, Denies ear drainage, tinnitus. Nose- Reports rhinorrhea, nasal congestion, denies epistaxis. Throat- Denies pharyngitis, dysphagia, tonsillitis, neck pain.
*SKIN:
*CARDIOVASCULAR:
*RESPIRATORY:
*GASTROINTESTINAL: Reported loose stools x 2 this AM. Denies bloody stools, abdominal pain. Denies N/V.
*GENITOURINARY:
*NEUROLOGICAL:
*MUSCULOSKELETAL:
*HEMATOLOGIC:
*LYMPHATICS:
*PSYCHIATRIC:
*ENDOCRINOLOGIC:
*ALLERGIES:
Objective.:
Vital signs: BP 98/60; A Pulse 110 bpm; RR 18; T 99.1; Pulse ox: 99% on R.A, Wt: 60lbs; Ht: 51”; BMI: 16.2
((Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. ))
General: Healthy, well nourished child, alert & Ox4, pleasant, appears with no distress, & answers questions appropriately for age level, sitting upright, but appears upset with frown and slight grimace.
HEENT: Head- normocephalic, symmetrical, no masses or trauma evident. Eyes- PERRLA, sclera is white, no conjunctivitis, drainage, or ptosis. Ears- On otoscopic exam, able to visualize TM intact, pearly gray, auditory canal has inflammation, erythema, visible object (popcorn kernel present) in canal. Nose- Nares patent bilaterally, pink mucosa, septum midline, clear nasal discharge. Neck- Full ROM, nontender, supple, symmetrical. Throat- no posterior oropharyngeal edema, lesions, or erythema. No masses palpated or cervical adenopathy noted, thyroid is midline. No tonsillitis noted upon exam.
Cardiovascular:
Respiratory:
GI:
Nervous:
Diagnostic tests & results: Include any labs, x-rays, or other diagnostics and results that are needed to develop the differential diagnoses (support with evidence and guidelines) and results that support the primary diagnosis of otitis media.
CBC- show elevated WBC’s
Otoscopy-
Pneumatic Otoscopy
Assessment:
Differential Diagnoses (list 5 other differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines why possible or ruled out.
1. Otitis media, nonsuppurative right ear ICD-10 Code: H65.91
2. Otitis Externa
3. Tympanosclerosis
4. Ear Trauma
5. Otitis-conjunctivitis syndrome
Plan:
Pharmacological Intervention:
Non-pharmacological Interventions:
Referrals:
Consults:
Health Maintenance:
Patient Education:
Follow-up visit if needed:
Reflection Statement:
References
You are required to include at 4 evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostic tests and differentials diagnosis.

2. Please answer the questions in a separate document from the SOAP note and attach.
1. What additional questions would you ask Annabelle and her mother today? –
2. Do you agree with mom that 99.4 is a significant fever? Why or why not?
3. What will your focused physical exam include?
4. When you look inside Annabelle’s right ear, you visualize what appears to be a piece of popcorn sitting in outer two-thirds of the external auditory canal. The canal is red and has swelled slightly but you can see around the kernel. TM appears gray. In deciding how to proceed, you think about your options. Should you irrigate the ear with water? Why or why not?

5. Prior to any type of procedure, you have the mother sign an informed consent for a procedure. What are the three major areas you must discuss when doing any type of procedure?

6. When removing a popcorn kernel from her ear, you seat Annabelle with the affected ear facing you. She is quite calm and cooperative. You decide to use a curette to try to get behind the kernel to pull it out. Why is it important to keep a hand resting on her head while using the curette?
7. You remove the kernel from her ear! Since the EAC is quite swollen and red, and somewhat abraded from the curette, what might you prescribe for her? Please list the directions as you would put them in a prescription.
(You should pick an appropriate otic topical antibiotic and list the patient/mother directions appropriately so the mother can understand).

8. What would be your post procedure education?
Example: Use all of the medication as prescribed; FU in one to two days if you report the following: headache, fever, drainage, and/or severe pain from ear. **** Use APA style. **** Provide 4-5 scholarly references to complete SOAP and questions.