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Asked by kayladuh7

Patient Info:    Jack is a 7-year-old established patient last seen 2 months ago for well child visit.  He is accompanied by his mother. 

Chief Complaint:            “My ear really hurts.”

History of Present Illness:   Family has been at Disney World and flew home 2 days ago.  Mom reports Jack developed cold symptoms 2-3 days before returning home.  Woke during the night, tearful and complaining of right ear pain.

Past Medical History:     Environmental Allergies

                                            Recurrent episodes of OM as a toddler

Past Surgical History:    Adenoidectomy and myringotomy tubes 2014

Family History:               Both parents alive and healthy; 4-year-old brother with asthma

Allergies:                          Environmental; no drug or food allergies

Medications:                    Loratadine 5 mg daily; daily multivitamin

Immunizations:               Up to date for age

Social History:                Lives with parents and brother in a single family home in suburban community. Is a first grader in a community public school where he does well and has many friends.  Father is a smoker and tries to smoke outside the home. Mother is stay-at-home mom.

Physical Exam:     
Vital Signs:  BP: 84/56      HR:  94        RR:  20      Temp: 100.8     Wt: 44 lbs (25th %)         Ht: 48″ (50th %)

 

 

1. What possible physical exam findings might you see with someone like Jack?

 

2. What are 3 of Jack’s differential diagnoses, and what 3 things may rule in or out each particular diagnosis?

 

3. What are at least 5 critical education pieces to share with Jack’s mother?

SCIENCE
HEALTH SCIENCE
NURSING
NU 745

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