Answer

Social History:

· The patient is a minor and lives with his parents and siblings. Has no history of smoking or alcohol consumption. Does not take any illicit drugs and has no job.

Sexual Orientation

· Not applicable in this case as the patient is still a minor

Diet:

· Patients agree to take an unbalanced diet on most occasions.

Subjective data:

Major Complaint: Patient complains of mild to severe ear pain

The History of Present Illness:-

The patient is a seventeen years old schoolboy who is complaining of occasional mild to severe ear pain. The patient also talks about irritation in the ear, a feeling of fullness inside the ear, headaches, lack of balance, fluid flowing out of the ear, and neck pain, among other symptoms. He complains that the symptoms have taken more than two weeks and denies chest pain, eye problems, or shortness of breath. The patient states that the situation is worse when exposed to different climates and Cold or flu. The ear was examined with samples of the fluid from the collection for lab examination. The patient also underwent two various ear tests to determine the eardrum's state and causes of fluid inside the ear.

Review of systems (ROS)

Constitutional: patient agrees to have Cold and flu. The patient Accepts to be weak. Denies eye loss

Neurological: LOC is normal. Denies any history of ear problems and accepts headaches, neck pain, ear pain, and dizziness.

HEENT:

Head- No injury on the head, no changes in the level of consciousness

Eye- Normal with no changes in vision or eye pain

Ear- complains of severe internal ear pain, reports discharge from the ear.

Nose- No pain in the nose, nasal drainage, especially when having a cold or flu

Throat- the patient receives pain when swallowing and neck pain, sore throats.

Respiratory: Patient denies shortness of breath, patients agrees to experience dry coughs which accelerates ear pain

Cardiovascular: Working normally

Gastrointestinal: The patient reports cases of diarrhea, vomiting, and discomfort.

Genitourinary- Not applicable in this case

Musculoskeletal: The patient reports being weak and not stable when walking or standing

Skin: Normal with no changes noticeable

(OD) Objective Data

The vital signs: Temperature- 39 °C: RR-28: Blood pressure-100/65: Reported pain 9/10

The General Appearance of the patient: Appears weak and in pain. Looks pale and sensitive to any sounding noise

Neurologic: The patient is alert and well oriented to place, time, and people. He is sensitive to noise, touché on his ear, and generally weak.

HEENT:

Head- Normal but sensitive to touch and tender

Eyes- Working normally, No visual changes, and not sensitive to light

Ears- Inflammation of the middle ear and fluid accumulation in the middle ear with discharge from inside the ear are observed. Tympanic membranes are bulged and tender. Middle ear effusion is observed.

Nose- Normal mucosa discharge

Neck- Thyroid swelling

Throat- sore in the throat

Cardiovascular: Normal

Respiratory: In normal condition

Gastrointestinal: Looks normal

Musculoskeletal: unstable Rate of Motion. Pain in the joints

Integumentary: Not applicable in this case

ASSESSMENT:

The primary diagnosis:

The diagnosis of this patient is determined by the several tests done as per the patient’s examination. Laboratory examination is used to determine the nature of illnesses the patient. As per the symptoms of severe ear pain and discharge from inside the ear, the patient is likely to be suffering from Right Otitis Media. This fact is given symptoms such as irritation, mild to severe ear pain, tests which reveal Temperature of about 39 °C: RR of 28: Blood pressure-100/65, and Reported problem of 9/10 (Grindle, 2015). One of the lab findings determines the discharger because of a bacterial or viral infection in the inner ear. Then the patient is declared to be suffering from Right Otitis Media.

The differential diagnosis:-

These include:

· External Otitis

· Herpes zoster infection

· Chronic otitis media

· Otitis media with effusion

· Chronic neck and head infections (Preciado, 2015).

The plan

The diagnostic and lab tests to be done:-

· Tympanocentesis

· Tympanometry

· Blood test

· Hearing tests

Medical treatment

· The doctor recommends acetaminophen. For the treatment of mild to severe pain

· cephalosporin, as directed by the doctor- Kills bacteria (Peterson & Reintjes, 2016).

Non-Medical treatment:

· intake of a well-balanced diet

· Eating ginger

· Avoid smoking

· Whish hands regular and disinfects all the services to prevent infections

· Use of warm and cold compressors to regulate the climate

· Consumption of garlic oil

Patient education:

· The patient is trained on the importance of following the doctor’s prescription throughout the treatment period.

· Look for any side effects of the drugs administered and report them immediately to the doctor.

· Education on the possibility of leading to other complications such as high blood pressure, hypertension, and severe headaches.

· The patient is educated on the importance of maintaining hygiene and avoiding inserting objects in the ears to prevent infections.

· Education on the elegies, which might make the situation worse, is also given for the patient to avoid weather and climatic conditions, which could be severe for the disease.

Follow up and special referrals:-

· Plans were made for a follow up to be done on the patient in four weeks. During these follow-ups, the doctor will be examining any signs of persistent Right Otitis Media. During this follow-up, the doctor will also determine the effectiveness of the medication recommended. Symptoms of discharge in the ear will also be resolved with the patient being examined for persistent pain. The patient will also be subjected to more tests to determine the hearing capability and progress in reducing the infections.

· At the moment, the patient will not be accorded any special referral. However, if the condition seems to get worse, the patient could be referred to a bigger hospital for advanced treatment. If the patient responds positively, a referral will not be required for him.

References