Sick Kid SOAP

Sick Kid SOAP
Otitis Externa
Elijah Hanna PA-S
Lock Haven University PA Program
Name: **** *******
Race & Gender: African-American Female
Insurance: Blue Cross/Blue Shield
Date Of Birth: 8/20/2003
Date: 6/01/2012
CC: “Both of my ears have been hurting for the past two days.”
HPI: 8-year-old African-American female presents to the clinic with her
grandmother for bilateral ear pain going on for the past two days. Patient says that
two days ago she noticed both ears were mildly tender, and “achey.” She rates the
initial pain as a 2/10. She says they got worse over night and yesterday she woke up
with rather exquisite pain rated as a 6/10. The pain was always just in her ear and
did not radiate elsewhere. It is constant and she says how it is hard to get to sleep
because of it. She says the pain is the same today and she now feels some fullness of
both ears and they are pruritic. Patient and grandmother said they have tried
nothing to help alleviate the symptoms, and nothing helps the pain. Patient says
touching her ears makes it worse, and especially laying her head down. She has
never had anything like this before, and has no history of otitis media or externa.
Patient and grandmother deny any fever, ear discharge, dizziness, vertigo, hearing
disturbances, radiating pain to mastoid process or surrounding area, difficulty with
mastication, eye pain, visual disturbances, nausea, or vomiting. Patient says that on
Tuesday (three days ago) she went to a friend’s house where they were swimming
in a pool and hot tub. She says that both the pool and hot tub seemed like they were
clean and well kept, and the grandmother confirmed. Patient says she was in the hot
tub and pool for a combined three hours, and submerged her head in both. Patient
and grandmother deny using any instruments to clean her ears, any skin conditions
like eczema, allergic rhinitis, congenital illnesses or deformities, and any coexisting
diseases such as diabetes. However, the child does have a history of asthma and uses
her rescue inhaler about 3 times in a month.
PMH: Patient has a history of asthma as stated in her HPI and was diagnosed 6
months ago. Patient and grandmother deny prenatal or delivery complications.
Patient has had regular well child visits with no pertinent history. Patient has no
history of chronic illnesses, anemia, congenital diseases/deformities, food
intolerances, or trauma.
Immunizations: Up to date
Illnesses/Injuries: None
Surgeries: None
Hospitalizations: None
Medications: Ventolin prn for asthma attacks (~3x’s a month)
Herbs/Vitamins: None
Allergies: No known drug, food or insect allergies
Family History:
Father- 32 years old, alive and well
Mother-31 years old, alive and well
Sister- 10 years old, alive and well
Paternal Grandfather- Deceased, MI at age 58
Paternal Grandmother- 60 years old, DM type 2, Hyperlipidemia, Obesity
Maternal Grandfather- 52 years old, alive and well
Maternal Grandmother- 51 years old, alive and well
Social History: Patient lives with mother, father, sister and paternal grandmother
in a residential home. Both parents are self-employed business owners of a
restaurant. The family reports good financial standing and a good home
environment. There are no tobacco, alcohol, or drug users in the home. There are no
firearms or pets in the home. The patient claims to eat a well-balance diet, and the
grandmother confirms she is not a picky eater. The patient just finished the third
grade and is in good academic standing. Grandmother confirms good sleep pattern
of about 8 hours a night. The child plays with sister and neighborhood friends. The
child sits in the backseat, wears a seat belt, knows how to swim, and wears a helmet
when she rides her bike.
Review of Systems:
General: Patient denies any fever, weight loss/gain, fatigue, weakness, appetite loss,
chills, or night sweats. Patient does say she has difficulty sleeping due to ear pain for
the last two days.
Skin: Patient denies any rashes, itching, bruising, dryness, redness or lesions.
Patient denies any other changes to hair, skin or nails.
HEENT: Patient denies any head trauma, headache, tenderness, dizziness, or
syncope. Patient denies any corrective lenses, visual disturbances/loss,
inflammation, discharge, dryness, excessive lacrimation, or pain of the eyes. (Ear Hx.
in HPI). Patient denies any sinus congestion/pressure, epistaxis, obstruction, polyps,
discharge or smell disturbances/loss. Patient denies any gum inflammation,
bleeding, ulcerations, pain, or lesions. Her last dental visit was two weeks ago, and
she had no dental carries.
Neck: Patient denies any tenderness, masses, stiffness, or lesions.
Respiratory: Patient denies any chest pain, dyspnea, cough, sputum production,
hemoptysis, or history of infection of influenza/pneumococcal/TB.
Cardiac: Patient denies any chest pain, dyspnea on exertion, palpitations, murmurs
or congenital abnormalities/complications.
Musculoskeletal: Patient denies any joint pain, swelling, redness, or stiffness.
Patient denies any muscle pain, weakness, or limitations in range of motion.
Lymphatic: Patient denies any lymphadenopathy of occipital, pre/post auricular,
submandibular, subtonsillar, submental, anterior/posterior cervical,
supra/infraclavicular, axillary, or inguinal lymph nodes.
Physical Exam:
Vitals: Temperature-97.4F (Oral), Heart Rate- 90 bpm, Respiration Rate- 18 bpm,
Blood Pressure- 117/60, Height- 55.5 in, Weight 89 lbs., BMI-20.31 kg/m2
General: Patient appears well developed, well nourished, consistent with stated age
and in no acute distress. The patient seems to be in a good mood, but holds her ears
when she talks about them.
Skin: There are no rashes, eruptions, scars, dryness or lesions. The hair is in
appropriate distribution, smooth, and well kept. There is no clubbing, merckes lines,
beaus lines, thickening, pallor, or pitting of the nails.
Head: The head is normocephalic and appropriate in size. There is no tenderness to
palpation, redness, swelling, increased warmth, or lesions. Appropriate facies were
bilateral, and no evidence of any facial nerve paralysis.
Eyes: The conjunctiva is moist, pink and not injected with no pallor bilaterally. The
sclera is white and moist bilaterally. There are no lesions, swelling, excessive
lacrimation or discharge noted bilaterally. Pupils are size 3, round, and symmetrical
bilaterally. Pupils show appropriate direct and consensual light reaction with
accommodation. Extra ocular eye movements are intact bilaterally with no lid lag or
nystagmus. Visual acuity is 20/20 bilaterally with color distinction intact.
Fundoscopic exam reveals red reflex, 2:1 cup to disc ratio, and no AV nicking, cotton
wool spots, hemorrhages, papilledema, and abnormal AV ratio bilaterally.
Ears: External inspection reveals symmetrical ears in size, shape and structures.
There is some whitish/yellow crusting bilaterally. Pain was elicited with palpation
of the tragus and pinna bilaterally. Patient had no pain with palpation to the mastoid
process bilaterally. Patient had no gross hearing abnormalities, and had equal
hearing distribution with a Weber test. Upon otoscope examination the external
auditory canal was inflamed, erythematous and partially obstructed with a
white/yellow discharge bilaterally. The tympanic membranes were visualized
bilaterally with slight erythematous injection on the outer margins and a pearl gray
color centrally. The pars tensa, pars flaccida, handle of the malleus, short process of
malleus, and cone of light in inferior nasal quadrant was visualized bilaterally. There
was no evidence of perforation, bulging, or inner ear effusion bilaterally.
Nose: Patient had no obvious lumps, bumps or lesions. There was no discharge or
redness noted from the nostrils. The septum was intact. The mucosal color was a
fleshy pink color, the turbinates were patent, and patient could breath through both
nostrils without difficult.
Throat: Vermillion border had no lesions, redness or chielosis. The tongue and
uvula are midline. The patient was able to move tongue from side to side and the
uvula had appropriate, symmetrical movement with phonation. The patient had
healthy dentition, a pink/moist oral mucosa, non-enlarged or exudative tonsils, and
unobstructed or erythematous Stenson’s and Wharton’s ducts. There were no
lesions, ulcers or masses in the oral or pharynx mucosa.
Neck: Inspection reveals the trachea midline and no masses, lesions, masses or
pulsations. Patient had no carotid bruits upon auscultation. No pain upon palpation
and full active range of motion. The thyroid was palpated with no evidence of
enlargement, masses or nodules. The patient was able to swallow without difficulty.
Chest/Lungs: Inspection reveals no scars, lesions, masses, accessory muscle use or
asymmetrical chest wall movements. Patient has no pain upon palpation, 1:2
AP/lateral ratio, and symmetrical respiratory excursion. Auscultation reveals clear,
unlabored breath sounds in all lung fields and no adventitious sounds such as rales,
ronchi, or wheezes.
Cardiac: Inspection of precordium reveals no lifts, heaves or visible PMI. Palpation
reveals no lifts, heaves or thrills. Auscultation reveals regular rate and rhythm, S1,
S2 and no murmurs, clicks, gallops or rubs. Pulses felt at radial and femoral arteries
with equal +2 intensity bilaterally.
Lymphatic: Occipital, pre/post auricular, submandibular, subtonsillar, submental,
anterior/posterior cervical, supr/infraclavicular, axillary and femoral lymph nodes
were non palpable.
Assessment: Diagnosis: Bilateral Otitis Externa
Differential Diagnosis Considerations: Otitis media, chronic suppurative otitis media,
and cholesteatoma.
Labs: None
Treatment: Ofloxacin 0.3% Ear Drops, 5 drops to each ear once a day for 10 days
Patient Education: Patient and grandmother educated on probable infection
causing bug, pseudomonas aeurginosa, that is common in polluted pools and hot
tubs. The patient is instructed to ensure the pool or hot tub is not contaminated
prior to swimming. Patient is encouraged to avoid submerging her head in hot tub.
Patient is told to keep ears dry after water exposure by using a hair dryer, and can
even avoid water exposure with earplugs when swimming. Patient is discouraged
from using any instruments to clean ear to avoid abrasion, obstruction and
introduction of infection. Patient is told to apply 5 eardrops to each ear once a day,
and the ears should be clean and dry before application. Patient is told that the pain
should begin to decrease within the next 24-48 hours.
Referrals: None
Provider Notes: With no prior history of ear complications, complicated infection
and typical history for otitis externa no gram stain and culture is indicated. Possible
complications are necrotizing otitis externa, spreading infection, and systemic
infection that would all require aggressive treatment and stat referral to ENT.
Follow Up: Patient is told to follow up if symptoms persist or worsen. Patient and
grandmother are educated on concerns of the infection spreading to surrounding
areas or the blood. Patient is told to follow up immediately if she gets a fever,
sudden decrease in hearing, pain in the mastoid process or TMJ, or if the child
begins to feel sick and lethargic.
Elijah Hanna PA-S