Patient Information: A., 3 years old, female, race and ethnicity unknown.
Subjective
Chief Complaint (from the mother’s word) — a cold; (from the child’s word) — an earache.
HPI
A 3-year-old A. girl is experiencing ear pain, which first started three days ago. The nature of the pain is not reported, but additional signs of inflammation are a yellowish fluid discharge during coughing. The discharge increases during crying when the child coughs heavily.
A., a three-year-old girl, suffers from a cold syndrome, and the pain is felt mainly in the ear area. Signs of the disease first appeared three days ago, but the nature of this pain is not specified. Additional signs are fever, nasal congestion and cough accompanied by a yellowish fluid discharge from the ears, especially intensifying when coughing and crying.
Current Medications: no current medications are reported, but it is stated that A. has no serious medical history.
Allergies: no drug or food allergies have been reported.
PMHx: A.’s current immunization status includes DTaP, Hib, HepB, MMR, Varicella, PCV13 vaccines.
Soc Hx: A. is a child; the composition of the family is not specified. He attends kindergarten most of the time and is in close contact with other children. There is a humidifier in the house, and an air conditioning system.
Fam Hx: family illnesses include bronchial asthma (father) and food allergies to citrus products (grandmother), but none of the illnesses have been reported as causes of death in relatives.
ROS
GENERAL: Colds, fever.
HEENT: Ears: Pain in the ears, yellowish fluid discharge that gets worse with coughing. Nose: nasal congestion. Sore throat: Feathering, causing coughing.
RESPIRATORY: Difficult breathing, caused by stuffy nose.
NEUROLOGICAL: Presence of pain in the ear area, nervousness caused by being in the doctor’s office, crying. Headache denied.
No information was offered for the other body systems.
Objective
Physical exam:
- GENERAL: A. looks depressed and frightened, has a body temperature of 99.86 °F.
- HEENT: Ears: the inner area of the ears is inflamed, has a reddish tinge, moist. A yellowish viscous fluid secretion is observed. On request to cough, the secretion of fluid increases. Nose: stuffy right nostril, minimal lumen, inner walls red and inflamed. Throat: redness, moist throat observed. The tonsils are inflamed. No white spots or signs of decay are observed.
- RESPIRATORY: slight rales are observed when listening to the lungs.
- NEUROLOGICAL: reflexes (knee, eye) are clean, functional, patient A. is conscious and aware of being in the doctor’s office. Equilibrium is maintained, motor function is normal.
Diagnostic results: to establish the differential diagnosis of A., a laboratory blood test should be performed to determine the potential infection. Determining the nature of the infection (bacterial or viral) is possible with a nasal and/or throat swab, especially from areas of increased inflammation (Keilman, 2019). Otoscopic diagnosis is necessary for detailed examination of ear discharges (Kleinman et al., 2021). At this time, a CT scan of the auricular cavities is not required but may be used when there is a complication of disease signs (Silva et al., 2018).
Assessment
Differential Diagnoses
Otitis media. For Otitis media, the usual symptoms are inflammation of the ear cavity leading to elevated body temperature, ear pain, and cough (Vanneste & Page, 2019). Infectious diseases may be the cause of yellowish fluid coming out of the ears.
Acute viral infection of the upper respiratory tract (URI). Most symptoms, including fever, stuffy nose, and colds, are consistent with the diagnosis of URI (Lehtoranta et al., 2020). The case’s neglect (lack of treatment in the first three days) may cause the infection to proliferate into the middle ear canal, resulting in an additional focus of infection and the discharge of yellowish fluids.
Allergic rhinitis. Allergic rhinitis can cause nasal congestion, sore throat, and cough if the child has unspecified allergies (Meng et al., 2019). In advanced cases, rhinitis can lead to elevated body temperature, especially when the child is stressed, as well as compromised immunity and concomitant infections, including ear infections.
References
Keilman, L. J. (2019). Seasonal influenza (flu). Nursing Clinics, 54(2), 227-243. Web.
Kleinman, K., Psoter, K. J., Nyhan, A., Solomon, B. S., Kim, J. M., & Canares, T. (2021). Evaluation of digital otoscopy in pediatric patients: A prospective randomized controlled clinical trial. The American Journal of Emergency Medicine, 46, 150-155. Web.
Lehtoranta, L., Latvala, S., & Lehtinen, M. J. (2020). Role of probiotics in stimulating the immune system in viral respiratory tract infections: A narrative review. Nutrients, 12(10), 1-19. Web.
Meng, Y., Wang, C., & Zhang, L. (2019). Recent developments and highlights in allergic rhinitis. Allergy, 74(12), 2320-2328. Web.
Silva, C., Pereira, G., Carneiro, R., & Brito, M. J. A. (2018). Case of flu and many complications [PDF document]. Web.
Vanneste, P., & Page, C. (2019). Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review. Journal of Otology, 14(2), 33-39. Web.