case Study #3 Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked
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Cc: “Earache right ear”
HPI: Patient is an 11-year-old Caucasian boy who was brought in by his grandmother after complaining about having a mild earache for the past two days. Patient states that the pain is worse when he falls asleep and that it has become harder for him to hear, grandmother believes that he feels warm but has not taken his temperature
Medications: Patient does not take any medications
PMH: No significant illnesses, shots are up to date
FH: No history of previous ear concerns no family history of ear disease. During the school year, patient lives at home with his mother, father and he does not have pets. Patient is staying with grandmother and grandfather most of summer
SH: Student in public school and is currently on summer break, has been spending a lot of time this summer in the pool per his grandmother that he is spending the summer with.
ROS: general: negative for chills fever currently
EENT: complains of mild right ear pain and mild hearing loss, denies tinnitus, denies pain in throat, or eye pain
VS: T 100.8, P 94, R 18, BP 98/64
General: Patient appears to be in mild pain, holding head to right side slightly
HEENT: right tympanic membrane obscured, ear canal is read and has a musty odor from ear canal with small amount of watery drainage, head is normocephalic without signs of trauma, no nasal drainage, PEARL, no complaints of sore throat, no redness in throat
SKIN: Warm and dry, good skin turgor, prominent tan
NECK: No lymph node edema or signs of pain on palpation
NEUROLOGICAL: No complaints of headache or dizziness
Diagnostic results. WBC slightly elevated, low grade temp
1) Acute Otitis Externa
2) Acute Otitis Media
Primary diagnoses/presumptive diagnoses: Acute otitis media
P – not indicated per template
Assessing for a possible ear infection would require additional information from the patient in addition to a physical assessment of the ear and the patient. Obtaining background information including recent travel, activities, family history, trauma, history of previous illnesses and treatments that have been used for treatment that were successful or not successful.
Diagnostic studies used to diagnose the specific pathogen would include obtaining a culture of purulent drainage, simple otoscopy was mostly used for diagnosing AOM (D’silva, 2013) or a more invasive way of evaluating white blood cell elevation is by completing a CBC which is not used as often as visual inspection of the ear canal. White blood cell count (WBC), a classical inflammation marker, is also used in many scoring systems during routine daily clinical practice (Kutlucan et al., n.d.). Using data from a CBC can also provide information about the patient’s overall health.
Acute otitis externa is the most common infection of the external auditory canal (Demirel et al., 2018). Ball describes (2015) symptoms of otitis externa as having watery to purulent and thick drainage mixed with pus with a musty odor and usually occurs after swimming.
Acute otitis media
Acute otitis media is one of the most frequent bacterial infections in children, and one of the primary reasons for the prescription of antibiotics by pediatricians (Intakorn, n.d.). Otitis media can have an abrupt onset with fever, feeling of a blockage, and interferes with sleep. The middle ear fills with pus causing conductive hearing loss (Ball).
Acute respiratory infections are one of the most common diseases, accounting for one of the main causes of patient visits to community health centers and hospitals (Yuniar, 2017). Ball (2015) describes a patient with acute pharyngitis as having a sore throat with deferred pain in ears and dysphagia with fever, malaise, fetid breath, abdominal pain and headache.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W. (2015). Seidel’s guide to
physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Demirel, H., Arlı, C., Özgür, T., İnci, M., & Dokuyucu, R. (2018). The Role of Topical
Thymoquinone in the Treatment of Acute Otitis Externa; an Experimental Study in
Rats. Journal of International Advanced Otology, 14(2), 285–289. https://doi-
D’silva, L., Parikh, R., Nanivadekar, A., & Joglekar, S. (2013). A Questionnaire-Based Survey
of Indian ENT Surgeons to Estimate Clinic Prevalence of Acute Otitis Media, Diagnostic
Practices, and Management Strategies. Indian Journal of Otolaryngology & Head & Neck
Surgery, 65, 575–581. https://doi-org.ezp.waldenulibrary.org/10.1007/s12070-012-0545-2
Intakorn, P., Sonsuwan, N., Noknu, S., Moungthong, G., Pircon, J.-Y., Liu, Y., … Hausdorff, W.
P. (n.d.). Haemophilus influenzae type b as an important cause of culture-positive acute
otitis media in young children in Thailand: a tympanocentesis-based, multi-center, cross-
sectional study. BMC PEDIATRICS, 14. https://doi-org.ezp.waldenulibrary.org
Kutlucan, L., Kutlucan, A., Basaran, B., Dagli, M., Basturk, A., Kozanhan, B., … Kos, M. (n.d.).
The predictive effect of initial complete blood count of intensive care unit patients on
mortality, length of hospitalization, and nosocomial infections. EUROPEAN REVIEW
FOR MEDICAL AND PHARMACOLOGICAL SCIENCES, 20(8), 1467–1473.
Yuniar, C. T., Anggadiredja, K., & Islamiyah, A. N. (2017). Evaluation of Rational Drug Use for
Acute Pharyngitis Associated with the Incidence and Prevalence of the Disease at Two
Community Health Centers in Indonesia. Scientia Pharmaceutica, 85(2), 1–10.
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