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Case Study

Case Study Week 6

Julie, a 3 – year – old preschool child, presents to the office with a complaint of left ear pain for 2 days. She is accompanied by her mother, Mary. She has had an intermittent fever and her maximum temperature at home was 101 ° F (axillary). The pain is worse sometimes when she is lying down. The pain is occasionally relieved with the use of over – the – counter pain relievers. Julia has had no vomiting or diarrhea. She has had a slight runny nose, but no cough.

Subjective

Sleep: Julia sleeps approximately 10 hours at night and takes one 1 – hour nap at her preschool. She usually has no problems falling or staying asleep but since the ear pain has started, her sleep has been interrupted.

Objective

Julia’ s vital signs are taken, and her weight in the office today is 14 kg. Her temperature is slightly elevated at 38 ° C (temporal). Julia is alert and quiet, sitting in her mother’s lap. She appears well hydrated and well nourished.

HEENT: Julia s head is normocephalic. Her red reflexes are present bilaterally; and her pupils are equal, round, and reactive to light. There is no ocular discharge noted. Julia ’s external ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ear. On otoscopic examination, the right tympanic membrane (TM) is gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the TM. The left TM is erythematous and bulging with purulent fluid visible behind the TM. The TM is opaque with no light reflex or bony landmarks present. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Julia s mucous membranes are noted to be moist. She has 20 teeth present without evidence of caries. There are no lesions present in the oral cavity.

Questions

1. Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for ear pain?

2. What is the most likely differential diagnosis and why?

3. What is the plan of treatment, referral, and follow – up care?

4. Does this patient ’s psychosocial history affect how you might treat this case?

5. What if the patient lived in a rural setting?

Use APA 7th Edition Format and support your work with at least 3 peer-reviewed references within 5 years of publication. Remember that you need a cover page and a reference page. All paragraphs need to be cited properly. Please use headers. All responses must be in a narrative format and each paragraph must have at least 4 sentences. Lastly, you must have at least 2 pages of content, no greater than 4 pages, excluding cover page and reference page

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