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31/12/2020 Client: saad24vbs Deadline: 2 Day


Name: R. L


Date: 05/09/2018


Sex: M


Age/DOB/Place of Birth: 2 years 02/28/2015 /Miami, Florida


SUBJECTIVE


Historian: Patient is a 2 years old which is unable to give his medical history and has no developmental delay


Present Concerns/CC: “Member presents to the office with his mother who states “R.L is complaining of fever of 101.0 F during the last 3 days, diminished appetite, runny nose and he grabs his R ear often.”.


Child Profile: A 2 years old member presents to the office with his mother who states “R.L is complaining of fever of 101.0 F during the last 3 days, diminished appetite and he grabs his R ear often.” Her mother is concerned he may having an ear infection because he was playing with the house during the holy week. She states he is a healthy boy delivered at 40 weeks of gestation by C section. The pain was defined by observation from the child pulling of his ear during the visit.


Developmental Growth


As per mom, he recognizes names of familiar people, objects, and body parts, he follows simple instructions, he like to scribbles in a paper sheet and kicks a balls.


During the interview, he walks alone, Climbs onto and down from furniture unassisted, he was able to points to object or picture when it’s named for him, stands on tiptoe and Uses two- to four-word sentences


HPI:


A 2 years old member presents to the office with his mother who states “R.L is complaining of fever of 101F during the last 3 days, diminished appetite and he grabs his R ear often.”


Medications:


None


PMH:


Allergies: None


Medication Intolerances: none


Chronic Illnesses: none


Hospitalizations/Surgeries: None Immunizations: Up to date


Family History:


Maternal Grandmother: Alive – Hypertension, diabetes Mellitus type 2, osteoarthritis


Maternal Grandfather: Alive - Hypertension, gout


Paternal Grandmother: Unknown Medical History


Paternal Grandfather: Lives in another country


Father – healthy


Mother – healthy


Social History:


2 years old male member who lives in a house with his both parents. Both parents are realtors and they denied the use on any recreational drugs at home. No safety Hazards at home. Both parents involve in the client care and support. He attend to a daycare from Monday to Friday. He like music, to kick balls and to scribbles in a paper sheet. Client was dress properly and clean.



ROS


General


fever, diminished appetite,


;


Cardiovascular


Denies chest pain or tightness


Skin


Denies rash, bruising, skin tears, discoloration or lesions


Respiratory


Denies history of pneumonia


Pediatric SOAP Note


Eyes


White sclera, Pupil equal, round, react to light and accommodation


Gastrointestinal


Denies n/v/d, constipation, bowel movements daily, last bowel movement effective today, Eat regular meals and he drinks regular milk. Diminished Appetite


Ears


Pain defined by observation from the child pulling of his ear during the visit.


Genitourinary/Gynecological


Normal urination, Not bladder distension. Tanner 1


Nose/Mouth/Throat


Observed nasal clear drainage, not lymph node distension


Musculoskeletal


Denies history of scoliosis


Breast


Tanner 1, denies breast lumps


Neurological


Denies seizures, c/o generalized pain


Heme/Lymph/Endo


No pending labs


Psychiatric


Denies sleeping difficulties


OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart


Weight: 30.4 lbs


Temp: 100.0 F


BP: 95/64 mmHg


Height: 3”


Pulse: 111 x’


RR: 30 x’


SpO2: 96 % at Room air


SPo


General Appearance and parent‐child interaction


Client was dress properly and clean. Good rapport with mother.


Skin


Warm, dry, clean and intact. Mother denies rashes


HEENT


Head: hair evenly distributed. Eyes: pupils equal round reactive to light and accommodation. No conjunctivitis. Ears: Canal patent. R ear redness. Bilateral pearly grey with positive light reflex. Nose: nasal mucosa pink, Observed a clear discharge. No deviation to septum. Neck supple, full range of motion. No cervical lymphadenopathy. Oral mucosa moist and pink. Pharynx erythematous and with no exudates. Teeth are in good condition.


Cardiovascular


S1, S2 regular rate and rhythm.


Respiratory


Chest wall symmetric


Gastrointestinal


Abdomen soft non-tender, BS active in all four quadrants. No hepatosplenomegaly


Breast


Tanner I (male)


Genitourinary


Denies burning with urination


Musculoskeletal


Normal range of motion in all extremities as patient ambulates around the office, and c/o of generalized pain.


Neurological


Speech clear, good tone and coordination. Balance stable, gait steady, walks alone, Climbs onto and down from furniture unassisted


Psychiatric


AAOx3, well-groomed with clean clothing, maintain eye contact and answers questions appropriately to the best of his ability


In-house Lab Tests


none


(HEADSSSVG Assessment)


Patient lives with both parents, no pets at home. Mother states that he is safe at home, no concerns about safety hazards. Denies any guns or weapons in the home. He goes to a daycare from Monday to Friday. On weekends, he plays at home or he going out with his father.


Diagnosis


Differential diagnosis


H73.19 Myringitis: These patients may have no symptoms attributable to the middle ear.


H70.893 Mastoiditis: There is no edema, erythema, and tenderness over the mastoid process.


H71.90 Cholesteatoma: Patients may present with painless otorrhea and hearing loss. Opacification of the tympanic membrane may lead to a misdiagnosis of AOM



.


· Final diagnosis


· H65.01 Acute serous otitis media, right ear: A physical examination was normal except for findings of a slightly red left tympanic membrane with no middle-ear fluid and a bulging right tympanic membrane with white fluid behind it, obscuring the umbo (Hendley, 2002).


                      Plan


· Medication:


· Amoxicillin 80mg/kg, PO, Daily, x 7 days. Early diagnosis and treatment of AOM, including the rational use of antibiotics should be improved, by incorporating clinical algorithms in current outpatient guidelines and by supporting the use of otoscopy in primary care practice (Monasta, Ronfani, Marchetti, Montico, Brumatti, Bavcar, Barbiero & Tamburlini, 2012).


· Education:


· Hand hygiene


· Proper hydration


· Use tissue for mucous and dispose properly


· Instruct mother about Amoxicillin such: Shake the oral suspension (liquid) well just before you measure a dose. Measure the liquid with a special dose-measuring spoon or medicine cup, not with a regular table spoon.


· Take this medication for the full prescribed length of time. His symptoms may improve before the infection is completely cleared.


· Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If he has diarrhea that is watery or bloody, stop taking amoxicillin and call your doctor. Do not use anti-diarrhea medicine unless your doctor tells you to.


· You may store liquid amoxicillin in a refrigerator but do not allow it to freeze. Throw away any liquid amoxicillin that is not used within 14 days after it was mixed at the pharmacy.


· Avoid taking baths in pools




References


Monasta, L., Ronfani, L., Marchetti, F., Montico, M., Brumatti, L., Bavcar, A., Barbiero, C. & Tamburlini, G. (2012). Burden of disease caused by otitis media: systematic review and global estimates. Plos One. Retrieved from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0036226






Hendley, J. (2002). Otitis media. New England Journal of Medicine. 347: 1169-1174. Retrieved fromhttp://www.nejm.org/doi/full/10.1056/NEJMcp010944

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