Sample+5
•Download as DOC, PDF•
0 likes•7 views
The patient presented with right ear pain and nasal congestion. On examination, the right eardrum was bulging and infected. The assessment was acute right otitis media. The plan was to treat with amoxicillin suspension for 5 days and follow up as needed.
Report
Share
Report
Share
Recommended
Acute Otits Media in Infant
Acute Otits Media in Infant by\ Eman Salman
It was used for student presentation in ENT course rotation
I Hope you find what is helpful for your knowledge ♥
Conservative management of otitis media
Otitis is one of the most frequent diseases in early childhood and one of the reasons for first prescription of antibiotics.
Most frequently reported pediatric bacterial infection, with up to 85% of children experiencing an episode by the age of 3 years and many of them have to treat with medicine and surgical management is restricted
Acute Otitis Media
This document discusses acute otitis media (AOM), including its clinical presentation, causes, prevention strategies, goals of therapy, investigations, therapeutic choices, antibiotic treatment recommendations, and medications used. AOM is usually caused by viral or bacterial pathogens and can be treated with analgesics or antibiotics like amoxicillin depending on the patient's age, risk factors, and symptoms. The case presentation describes a 17 month old boy with symptoms of AOM who should be treated with antibiotics.
The ENT history and examination
The document provides guidance on taking patient history and performing examinations in ENT (ear, nose, and throat). It emphasizes the importance of the history in guiding examination and diagnosis. The history should explore the presenting complaint, past medical history, medications, and social factors. Key areas to examine include the ears, nose, mouth, larynx, neck, and facial nerves. Specific procedures are described for examining the external ear canal, ear drum, and performing tuning fork tests to evaluate hearing. Danger signs in the history that may indicate serious conditions are also highlighted.
Otitis media
Otitis media is an infection of the middle ear caused by viruses or bacteria that spreads from the nose and throat. Young children are more susceptible due to the anatomy of their eustachian tubes. Symptoms include ear pain, fever, and hearing loss. Diagnosis is made through physical exam showing a bulging eardrum or reduced mobility. Treatment involves pain medication and antibiotics like amoxicillin. Complications can include mastoiditis, hearing loss, or tube placement may be needed for persistent fluid.
approach to sore throat in children
1. The case discusses a 6-year-old child presenting with fever and throat pain for 4 days. On examination, the child has tonsillar enlargement with exudates and tender cervical lymphadenopathy.
2. Differential diagnoses for the child's symptoms include viral and bacterial pharyngitis. Key clinical indicators suggest this is likely a case of bacterial pharyngitis caused by Group A beta-hemolytic streptococcus (GABHS).
3. Treatment of the child includes general supportive measures, paracetamol for fever, and a 10-day course of amoxicillin based on the diagnosis of GABHS pharyngitis. Prompt diagnosis and treatment can prevent serious
Anaphylaxis
This document defines anaphylaxis and hypersensitivity reactions, describes the pathophysiology and etiology of anaphylaxis, and outlines signs/symptoms, diagnosis, and treatment. It discusses how anaphylaxis is a severe allergic reaction affecting multiple organ systems. Common triggers include foods, medications, insect bites, and latex. Diagnosis is based on symptoms occurring rapidly after exposure. Treatment involves epinephrine, antihistamines, corticosteroids, bronchodilators, and emergency management including CPR if needed.
Ent presentation
This document provides information on the diagnosis and management of acute otitis media (AOM). It defines AOM as a middle ear infection characterized by middle ear effusion and signs of inflammation. The most common causes are bacterial and viral infections. Complications can include hearing loss, perforation, and intracranial issues. Diagnosis is based on symptoms like earache in children or non-specific symptoms in younger children. Differential diagnoses and management strategies are discussed, including antibiotic use and referral criteria. Follow up is typically not needed unless symptoms worsen or persist after initial treatment.
Recommended
Acute Otits Media in Infant
Acute Otits Media in Infant by\ Eman Salman
It was used for student presentation in ENT course rotation
I Hope you find what is helpful for your knowledge ♥
Conservative management of otitis media
Otitis is one of the most frequent diseases in early childhood and one of the reasons for first prescription of antibiotics.
Most frequently reported pediatric bacterial infection, with up to 85% of children experiencing an episode by the age of 3 years and many of them have to treat with medicine and surgical management is restricted
Acute Otitis Media
This document discusses acute otitis media (AOM), including its clinical presentation, causes, prevention strategies, goals of therapy, investigations, therapeutic choices, antibiotic treatment recommendations, and medications used. AOM is usually caused by viral or bacterial pathogens and can be treated with analgesics or antibiotics like amoxicillin depending on the patient's age, risk factors, and symptoms. The case presentation describes a 17 month old boy with symptoms of AOM who should be treated with antibiotics.
The ENT history and examination
The document provides guidance on taking patient history and performing examinations in ENT (ear, nose, and throat). It emphasizes the importance of the history in guiding examination and diagnosis. The history should explore the presenting complaint, past medical history, medications, and social factors. Key areas to examine include the ears, nose, mouth, larynx, neck, and facial nerves. Specific procedures are described for examining the external ear canal, ear drum, and performing tuning fork tests to evaluate hearing. Danger signs in the history that may indicate serious conditions are also highlighted.
Otitis media
Otitis media is an infection of the middle ear caused by viruses or bacteria that spreads from the nose and throat. Young children are more susceptible due to the anatomy of their eustachian tubes. Symptoms include ear pain, fever, and hearing loss. Diagnosis is made through physical exam showing a bulging eardrum or reduced mobility. Treatment involves pain medication and antibiotics like amoxicillin. Complications can include mastoiditis, hearing loss, or tube placement may be needed for persistent fluid.
approach to sore throat in children
1. The case discusses a 6-year-old child presenting with fever and throat pain for 4 days. On examination, the child has tonsillar enlargement with exudates and tender cervical lymphadenopathy.
2. Differential diagnoses for the child's symptoms include viral and bacterial pharyngitis. Key clinical indicators suggest this is likely a case of bacterial pharyngitis caused by Group A beta-hemolytic streptococcus (GABHS).
3. Treatment of the child includes general supportive measures, paracetamol for fever, and a 10-day course of amoxicillin based on the diagnosis of GABHS pharyngitis. Prompt diagnosis and treatment can prevent serious
Anaphylaxis
This document defines anaphylaxis and hypersensitivity reactions, describes the pathophysiology and etiology of anaphylaxis, and outlines signs/symptoms, diagnosis, and treatment. It discusses how anaphylaxis is a severe allergic reaction affecting multiple organ systems. Common triggers include foods, medications, insect bites, and latex. Diagnosis is based on symptoms occurring rapidly after exposure. Treatment involves epinephrine, antihistamines, corticosteroids, bronchodilators, and emergency management including CPR if needed.
Ent presentation
This document provides information on the diagnosis and management of acute otitis media (AOM). It defines AOM as a middle ear infection characterized by middle ear effusion and signs of inflammation. The most common causes are bacterial and viral infections. Complications can include hearing loss, perforation, and intracranial issues. Diagnosis is based on symptoms like earache in children or non-specific symptoms in younger children. Differential diagnoses and management strategies are discussed, including antibiotic use and referral criteria. Follow up is typically not needed unless symptoms worsen or persist after initial treatment.
100 cases in ent ear and throat from air alshams university
Right chronic suppurative otitis media complicated by suppurative labyrinthitis and meningitis, leading to the death of a 10-year old child. Key manifestations included dizziness, nausea, vomiting, nystagmus, fever, severe headache and neck retraction. The child was not properly managed.
6512 Discussion wk 5.docx
Richard is a 50-year-old male presenting with nasal congestion, sneezing, rhinorrhea, and postnasal drainage for 5 days. On examination, he has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates obstructing airflow, but clear lungs and mildly erythematous throat. A focused history and physical exam is needed to determine if this is an upper respiratory infection or something more serious like sinusitis. Differential diagnoses could include the common cold, allergic rhinitis, sinusitis, and nasal polyps.
6512 Discussion wk 5.docx
Richard is a 50-year-old male presenting with nasal congestion, sneezing, rhinorrhea, and postnasal drainage for 5 days. On examination, he has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates obstructing airflow, but clear lungs and mildly erythematous throat. A focused SOAP note is written assessing Richard's case of presumed allergic rhinitis while considering other potential diagnoses.
Assessing the and Throat Essay.docx
This case involves a 20-year-old female college student presenting with a 3-day sore throat. Her symptoms include decreased appetite, headaches, pain with swallowing, runny nose, and slight hoarseness. On examination, she has no swollen lymph nodes or tonsils, but her throat is erythematous. Differential diagnoses could include strep throat, viral pharyngitis, or mononucleosis. Further history and physical exam are needed to guide diagnostic testing and diagnosis.
SOAP NOTEName N.CDate 10262020Time 09.30 h.docx
SOAP NOTE
Name:
N.C
Date:
10/26/2020
Time:
09.30 h
Age:
5-year-old
Sex:
M
CC:
"I have sore throat"
HPI:
A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.
Medications:
Tylenol OTC PO PRN
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations:
- According to CDC for his age group, he is up to date with the following vaccines
• Influenza 2019
• Tdap 5th dose
• MMR 2nd dose
• Polio IVP 4th dose
• Chickenpox (Varicella) 2nd dose
Family History:
Mother: Alive – no significant medical history
Father: Alive - HTN
Sister: 8 years old healthy
Brother: 2 days old healthy
Social History
Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.
General
Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies rash, inflammation, pain, tenderness, or skin lesion.
Respiratory
Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.
Eyes
Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.
ENT
Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.
Gastrointestinal
Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.
Genitourinary
Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.
Musculoskeletal
Denies back pain, joint swelling, stiffness, or muscle pain.
Heme/Lymph/Endo
Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.
Neurological
Denies any syncope, seizures, transient paralysis, paresthesi.
SEROUS OTITIS MEDIA.final.pptx
What specific questions you will ask to reach the diagnosis?
Give the differential diagnosis?
Give management plan of your diagnosis?
What complications can develop?
Write the treatment of your diagnosis?
This is an insidious condition characterized by accumulation of nonpurulent effusion in the middle ear cleft.
The effusion is mostly viscid and thick but sometimes it is thin and serous.
This condition is commonly seen in the school going children.
it is also known as;
Secretory otitis media.
Mucoid otitis media.
Glue ear.
25 Important Cases In Ear Nose Throat | SurgicoMed.com
Case 1: A 10 year old child was having a right mucopurulent otorrhea for the last 4 years. A
week ago he became dizzy with a whirling sensation, nausea, vomiting and nystagmus to the
opposite side; his deafness became complete and his temperature was normal. Three days later
he became feverish, irritable and continuously crying apparently from severe headache. Also he
had some neck retraction. The child was not managed properly and died by the end of the week.
Otitis Media
Otitis media, or ear infection, presents with ear pain in older patients and irritability in younger children and infants. On examination, the eardrum will be inflamed, bulging, and have reduced mobility. Treatment involves investigating for underlying illness, prescribing amoxicillin or alternative antibiotics like trimethoprim for 10 days if there is no recent antibiotic use or recurrent infections, and providing pain/fever relief. Follow-up is recommended for young children or if symptoms persist. Antihistamines and decongestants are not effective treatments. Amoxicillin remains the first choice antibiotic despite increasing antimicrobial resistance.
6512 Discussion wk 5 My Nursing Experts.pdf
This document discusses three case studies involving patients presenting with ear, nose, and throat symptoms. For Case 1, Richard presents with nasal congestion and drainage. A physical exam shows pale nasal mucosa and enlarged turbinates. For Case 2, Lily presents with a sore throat and symptoms of a viral infection. For Case 3, James presents with right ear pain and decreased hearing. He has spent time in the pool recently. The document provides guidance on collecting patient history, performing exams, selecting diagnostic tests, and generating differential diagnoses for the cases.
Case write up ent
This document provides biographical and medical history information for a 30-year-old Malay patient, Mr. IR, who was electively admitted for bilateral tonsillectomy with CAPSO under general anesthesia due to chronic snoring and recurrent tonsillitis. A physical examination revealed grade 3 bilaterally enlarged, erythematous tonsils with an erythematous uvula. The diagnosis was chronic tonsillitis causing obstructive sleep apnea, and the planned treatment was bilateral tonsillectomy with CAPSO under general anesthesia along with pre-operative testing.
Case Presentation on Chronic Otitis Media
Ms. Sunitha Rani, a 36-year-old married homemaker, was admitted to the ENT ward on March 18, 2024 for right acute otitis media, as she presented with ear pain, discharge from her right ear, and difficulty hearing on that side for the past few days.
APA format in a SOAP Note format. 1 page long with questions as to
APA format in a SOAP Note format. 1 page long with questions as to which diagnosis would be accurate and why. I have included the references I need 3 peer review articles to be included
Patient Information:
Initials
: JS
Age
: 11
Sex
: M
Race
: Caucasian
SJ
CC:
Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.
HPI
: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear. The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.
Current Medications
:
1. Ibuprofen 600mg PRN for earache pain
Allergies:
NKA
PMHx
: Up to date on all immunizations. No significant PMH.
Soc Hx
: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer.
Fam Hx
: Maternal grandmother died of a stroke at the age of 70. No other significant family history.
ROS
:
GENERAL: No fever, fatigue or chills. No weight loss.
HEENT:
Eyes:
No visual loss, blurred vision, double vision or yellow sclerae.
Ears:
Patient reporting pain in right ear and hearing loss.
Nose,
Throat:
No sneezing, congestion, runny nose or sore throat.
SKIN: No rashes or itching.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing.
HEENT: PEERLA.
Ears:
Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact.
Nose
: Nose is patent without any rhinorrhea.
Throat:
Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012).
SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good.
RESPIRATORY: LS CTA bilaterally, no sternal retractions noted.
GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present.
NEUROLOGICAL: Cranial ...
Case presentation on csom 1
A 36-year-old male presented with decreased hearing in both ears for 3 months. Physical examination and lab tests revealed chronic suppurative otitis media caused by bacteria like Pseudomonas aeruginosa. The patient was prescribed antibiotics like Augmentin to be taken before meals, antihistamine Levocitrizine to be taken in the evening, pantoprazole for gastric acid suppression, and diclofenac for pain relief. He was counseled on lifestyle modifications like avoiding inserting objects in ears and swimming until fully recovered.
persentasi laporan PBL Penghidu
The document discusses a 52-year-old man who presented with reduced sense of smell for 1 week and a history of bad breath. On examination, dried snot was found in his nose. The document then poses several questions and provides answers about the olfactory system, causes of reduced sense of smell, diseases that can cause it, possible causes of the patient's symptoms, how to diagnose, and differential diagnoses of sinusitis and nasal polyps.
Otitis externia.pptx
This document discusses a case study of a 6-year-old girl presenting with left ear pain and discharge for 5 days. On examination, her left ear canal was infected with purulent discharge and increased warmth. Guidelines recommend antibiotics such as amoxicillin for 5-7 days for acute otitis media in children. Prescribing for children requires considering differences from adults in drug pharmacokinetics, testing, and formulations. Clinical guidelines help inform appropriate treatment and review.
Case presentation Esthesioneuroblastoma Dr Utkal Mishra
This document presents a case report of a 42-year-old male patient who presented with a chief complaint of discharge from the right nostril for 2 months, nasal obstruction of both nostrils for 1 month, and headache for 10 days. On examination, a greyish-white, firm, non-tender mass was found filling the entire right nasal cavity. A provisional diagnosis of esthesioneuroblastoma of the right nasal cavity was made based on the history and examination findings.
4 laryngeal disorders
The document discusses various laryngeal disorders including acute epiglottitis, acute laryngitis, acute laryngitis in children, and chronic laryngitis.
Acute epiglottitis is a dangerous condition characterized by sudden swelling of the epiglottis which can cause airway obstruction. It requires immediate hospitalization, monitoring, antibiotics, steroids, and possibly tracheostomy.
Acute laryngitis is usually caused by a viral infection and causes hoarseness. It is typically self-limiting but requires voice rest, steam inhalation, and sometimes antibiotics/steroids.
Acute laryngitis in children can progress rapidly due to anatomical factors and cause str
Case report ramsey hunt
There was significant improvement in facial
paralysis and rash after 5 days of treatment. Patient was
discharged on tapering doses of steroids with advice to
follow up after 1 week.
Student Name Course Name Assignment Due Date Week 3 S.docx
Student Name:
Course Name:
Assignment Due Date:
Week 3 SOAP Note
Subjective Data:
Chief Complaint: coughing, follow-up lab results.
History of Present Illness: 37 year-old- Hispanic male, , who presents to the clinic for a follow up visit on abnormal triglyceride levels that were done 2 weeks ago, and a complaint of intermittent non-productive coughing x 2 weeks with mild clear nasal drainage and watery eyes. Cough worsens at night in supine position interfering with his sleep and is decreased during the day. Denies any. Constitutional symptoms or associated symptoms such as nasal congestion, headache, dyspnea or chest pain. Does anything make it better? Any OTC remedies? That all goes below.
Medications:
Lisinopril 20 mg once a day
Simvastatin 20 mg once a day
Metformin 1000 mg twice a day
Glimepiride 4 mg once a day
OTC- Loratadine 10mg once a day
Allergies: No known drug allergies or food allergies. Has seasonal allergies during spring and summer.Possibly environmental as well.
Past Medical History: hypertension, hyperlipidemia, diabetes, and seasonal allergies.
Past Surgical History: No past surgical history.
Personal/Social History: smokes one pack of cigarettes per day for 7 years. Still currently smoking. Drinks alcohol on occasion. Denies any drug use. States he does not exercise regularly and is not on any special diet, but is trying to start a diet and exercise program.
Immunizations: Up-to-date. Last DTAP was 2 years ago, flu shot was in November 2012.
Family History:. His father has diabetes and hypertension. His mother has hypertension and arthritis. He has one brother, still living with no medical problems. He is single, and has no children.
Review of Systems:
General: admits he is mildly obese, no recent weight change or loss, no fever, fatigue, or weakness.
Skin: reports no rashes, mumps, sores, itching, dryness.
Eyes: No changes in vision. No vertigo. No eye pain. Has watery eyes. Need to explain positive finding using the 7 variables
Ears: No recent hearing loss. No tinnitus. No ear discharge or ear pressure.
Nose: Seasonal allergies for which he takes Claritin but has been out for two months. Now symptoms are worsening. No nasal congestion. Has mild watery clear nasal discharge intermittently for three months with occasional cough at night. No epistaxis.
Throat: Denies sore throat. No hoarseness. No bleeding gums or dry mouth.
Neck: Denies neck pain or stiffness.
Respiratory: See HPI. Non-productive cough. No hemoptysis. No wheeze.
Cardiovascular: No palpitations, chest pain, edema, shortness of breath. States having history of diet controlled hypertension. Takes periodic readings at local pharmacy and ranges 130-140 systolic and 70 to 80 systolic. Has had difficulty controlling hyperlipedimia due to diet- likes eating fried food.
Gastrointestinal: No nausea, vomiting, diarrhea, constipation.
Endocrine: History DM type 2 which is control via diet and medication. Does not recall l.
More Related Content
Similar to Sample+5
100 cases in ent ear and throat from air alshams university
Right chronic suppurative otitis media complicated by suppurative labyrinthitis and meningitis, leading to the death of a 10-year old child. Key manifestations included dizziness, nausea, vomiting, nystagmus, fever, severe headache and neck retraction. The child was not properly managed.
6512 Discussion wk 5.docx
Richard is a 50-year-old male presenting with nasal congestion, sneezing, rhinorrhea, and postnasal drainage for 5 days. On examination, he has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates obstructing airflow, but clear lungs and mildly erythematous throat. A focused history and physical exam is needed to determine if this is an upper respiratory infection or something more serious like sinusitis. Differential diagnoses could include the common cold, allergic rhinitis, sinusitis, and nasal polyps.
6512 Discussion wk 5.docx
Richard is a 50-year-old male presenting with nasal congestion, sneezing, rhinorrhea, and postnasal drainage for 5 days. On examination, he has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates obstructing airflow, but clear lungs and mildly erythematous throat. A focused SOAP note is written assessing Richard's case of presumed allergic rhinitis while considering other potential diagnoses.
Assessing the and Throat Essay.docx
This case involves a 20-year-old female college student presenting with a 3-day sore throat. Her symptoms include decreased appetite, headaches, pain with swallowing, runny nose, and slight hoarseness. On examination, she has no swollen lymph nodes or tonsils, but her throat is erythematous. Differential diagnoses could include strep throat, viral pharyngitis, or mononucleosis. Further history and physical exam are needed to guide diagnostic testing and diagnosis.
SOAP NOTEName N.CDate 10262020Time 09.30 h.docx
SOAP NOTE
Name:
N.C
Date:
10/26/2020
Time:
09.30 h
Age:
5-year-old
Sex:
M
CC:
"I have sore throat"
HPI:
A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.
Medications:
Tylenol OTC PO PRN
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations:
- According to CDC for his age group, he is up to date with the following vaccines
• Influenza 2019
• Tdap 5th dose
• MMR 2nd dose
• Polio IVP 4th dose
• Chickenpox (Varicella) 2nd dose
Family History:
Mother: Alive – no significant medical history
Father: Alive - HTN
Sister: 8 years old healthy
Brother: 2 days old healthy
Social History
Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.
General
Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies rash, inflammation, pain, tenderness, or skin lesion.
Respiratory
Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.
Eyes
Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.
ENT
Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.
Gastrointestinal
Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.
Genitourinary
Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.
Musculoskeletal
Denies back pain, joint swelling, stiffness, or muscle pain.
Heme/Lymph/Endo
Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.
Neurological
Denies any syncope, seizures, transient paralysis, paresthesi.
SEROUS OTITIS MEDIA.final.pptx
What specific questions you will ask to reach the diagnosis?
Give the differential diagnosis?
Give management plan of your diagnosis?
What complications can develop?
Write the treatment of your diagnosis?
This is an insidious condition characterized by accumulation of nonpurulent effusion in the middle ear cleft.
The effusion is mostly viscid and thick but sometimes it is thin and serous.
This condition is commonly seen in the school going children.
it is also known as;
Secretory otitis media.
Mucoid otitis media.
Glue ear.
25 Important Cases In Ear Nose Throat | SurgicoMed.com
Case 1: A 10 year old child was having a right mucopurulent otorrhea for the last 4 years. A
week ago he became dizzy with a whirling sensation, nausea, vomiting and nystagmus to the
opposite side; his deafness became complete and his temperature was normal. Three days later
he became feverish, irritable and continuously crying apparently from severe headache. Also he
had some neck retraction. The child was not managed properly and died by the end of the week.
Otitis Media
Otitis media, or ear infection, presents with ear pain in older patients and irritability in younger children and infants. On examination, the eardrum will be inflamed, bulging, and have reduced mobility. Treatment involves investigating for underlying illness, prescribing amoxicillin or alternative antibiotics like trimethoprim for 10 days if there is no recent antibiotic use or recurrent infections, and providing pain/fever relief. Follow-up is recommended for young children or if symptoms persist. Antihistamines and decongestants are not effective treatments. Amoxicillin remains the first choice antibiotic despite increasing antimicrobial resistance.
6512 Discussion wk 5 My Nursing Experts.pdf
This document discusses three case studies involving patients presenting with ear, nose, and throat symptoms. For Case 1, Richard presents with nasal congestion and drainage. A physical exam shows pale nasal mucosa and enlarged turbinates. For Case 2, Lily presents with a sore throat and symptoms of a viral infection. For Case 3, James presents with right ear pain and decreased hearing. He has spent time in the pool recently. The document provides guidance on collecting patient history, performing exams, selecting diagnostic tests, and generating differential diagnoses for the cases.
Case write up ent
This document provides biographical and medical history information for a 30-year-old Malay patient, Mr. IR, who was electively admitted for bilateral tonsillectomy with CAPSO under general anesthesia due to chronic snoring and recurrent tonsillitis. A physical examination revealed grade 3 bilaterally enlarged, erythematous tonsils with an erythematous uvula. The diagnosis was chronic tonsillitis causing obstructive sleep apnea, and the planned treatment was bilateral tonsillectomy with CAPSO under general anesthesia along with pre-operative testing.
Case Presentation on Chronic Otitis Media
Ms. Sunitha Rani, a 36-year-old married homemaker, was admitted to the ENT ward on March 18, 2024 for right acute otitis media, as she presented with ear pain, discharge from her right ear, and difficulty hearing on that side for the past few days.
APA format in a SOAP Note format. 1 page long with questions as to
APA format in a SOAP Note format. 1 page long with questions as to which diagnosis would be accurate and why. I have included the references I need 3 peer review articles to be included
Patient Information:
Initials
: JS
Age
: 11
Sex
: M
Race
: Caucasian
SJ
CC:
Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.
HPI
: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear. The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.
Current Medications
:
1. Ibuprofen 600mg PRN for earache pain
Allergies:
NKA
PMHx
: Up to date on all immunizations. No significant PMH.
Soc Hx
: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer.
Fam Hx
: Maternal grandmother died of a stroke at the age of 70. No other significant family history.
ROS
:
GENERAL: No fever, fatigue or chills. No weight loss.
HEENT:
Eyes:
No visual loss, blurred vision, double vision or yellow sclerae.
Ears:
Patient reporting pain in right ear and hearing loss.
Nose,
Throat:
No sneezing, congestion, runny nose or sore throat.
SKIN: No rashes or itching.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing.
HEENT: PEERLA.
Ears:
Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact.
Nose
: Nose is patent without any rhinorrhea.
Throat:
Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012).
SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good.
RESPIRATORY: LS CTA bilaterally, no sternal retractions noted.
GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present.
NEUROLOGICAL: Cranial ...
Case presentation on csom 1
A 36-year-old male presented with decreased hearing in both ears for 3 months. Physical examination and lab tests revealed chronic suppurative otitis media caused by bacteria like Pseudomonas aeruginosa. The patient was prescribed antibiotics like Augmentin to be taken before meals, antihistamine Levocitrizine to be taken in the evening, pantoprazole for gastric acid suppression, and diclofenac for pain relief. He was counseled on lifestyle modifications like avoiding inserting objects in ears and swimming until fully recovered.
persentasi laporan PBL Penghidu
The document discusses a 52-year-old man who presented with reduced sense of smell for 1 week and a history of bad breath. On examination, dried snot was found in his nose. The document then poses several questions and provides answers about the olfactory system, causes of reduced sense of smell, diseases that can cause it, possible causes of the patient's symptoms, how to diagnose, and differential diagnoses of sinusitis and nasal polyps.
Otitis externia.pptx
This document discusses a case study of a 6-year-old girl presenting with left ear pain and discharge for 5 days. On examination, her left ear canal was infected with purulent discharge and increased warmth. Guidelines recommend antibiotics such as amoxicillin for 5-7 days for acute otitis media in children. Prescribing for children requires considering differences from adults in drug pharmacokinetics, testing, and formulations. Clinical guidelines help inform appropriate treatment and review.
Case presentation Esthesioneuroblastoma Dr Utkal Mishra
This document presents a case report of a 42-year-old male patient who presented with a chief complaint of discharge from the right nostril for 2 months, nasal obstruction of both nostrils for 1 month, and headache for 10 days. On examination, a greyish-white, firm, non-tender mass was found filling the entire right nasal cavity. A provisional diagnosis of esthesioneuroblastoma of the right nasal cavity was made based on the history and examination findings.
4 laryngeal disorders
The document discusses various laryngeal disorders including acute epiglottitis, acute laryngitis, acute laryngitis in children, and chronic laryngitis.
Acute epiglottitis is a dangerous condition characterized by sudden swelling of the epiglottis which can cause airway obstruction. It requires immediate hospitalization, monitoring, antibiotics, steroids, and possibly tracheostomy.
Acute laryngitis is usually caused by a viral infection and causes hoarseness. It is typically self-limiting but requires voice rest, steam inhalation, and sometimes antibiotics/steroids.
Acute laryngitis in children can progress rapidly due to anatomical factors and cause str
Case report ramsey hunt
There was significant improvement in facial
paralysis and rash after 5 days of treatment. Patient was
discharged on tapering doses of steroids with advice to
follow up after 1 week.
Student Name Course Name Assignment Due Date Week 3 S.docx
Student Name:
Course Name:
Assignment Due Date:
Week 3 SOAP Note
Subjective Data:
Chief Complaint: coughing, follow-up lab results.
History of Present Illness: 37 year-old- Hispanic male, , who presents to the clinic for a follow up visit on abnormal triglyceride levels that were done 2 weeks ago, and a complaint of intermittent non-productive coughing x 2 weeks with mild clear nasal drainage and watery eyes. Cough worsens at night in supine position interfering with his sleep and is decreased during the day. Denies any. Constitutional symptoms or associated symptoms such as nasal congestion, headache, dyspnea or chest pain. Does anything make it better? Any OTC remedies? That all goes below.
Medications:
Lisinopril 20 mg once a day
Simvastatin 20 mg once a day
Metformin 1000 mg twice a day
Glimepiride 4 mg once a day
OTC- Loratadine 10mg once a day
Allergies: No known drug allergies or food allergies. Has seasonal allergies during spring and summer.Possibly environmental as well.
Past Medical History: hypertension, hyperlipidemia, diabetes, and seasonal allergies.
Past Surgical History: No past surgical history.
Personal/Social History: smokes one pack of cigarettes per day for 7 years. Still currently smoking. Drinks alcohol on occasion. Denies any drug use. States he does not exercise regularly and is not on any special diet, but is trying to start a diet and exercise program.
Immunizations: Up-to-date. Last DTAP was 2 years ago, flu shot was in November 2012.
Family History:. His father has diabetes and hypertension. His mother has hypertension and arthritis. He has one brother, still living with no medical problems. He is single, and has no children.
Review of Systems:
General: admits he is mildly obese, no recent weight change or loss, no fever, fatigue, or weakness.
Skin: reports no rashes, mumps, sores, itching, dryness.
Eyes: No changes in vision. No vertigo. No eye pain. Has watery eyes. Need to explain positive finding using the 7 variables
Ears: No recent hearing loss. No tinnitus. No ear discharge or ear pressure.
Nose: Seasonal allergies for which he takes Claritin but has been out for two months. Now symptoms are worsening. No nasal congestion. Has mild watery clear nasal discharge intermittently for three months with occasional cough at night. No epistaxis.
Throat: Denies sore throat. No hoarseness. No bleeding gums or dry mouth.
Neck: Denies neck pain or stiffness.
Respiratory: See HPI. Non-productive cough. No hemoptysis. No wheeze.
Cardiovascular: No palpitations, chest pain, edema, shortness of breath. States having history of diet controlled hypertension. Takes periodic readings at local pharmacy and ranges 130-140 systolic and 70 to 80 systolic. Has had difficulty controlling hyperlipedimia due to diet- likes eating fried food.
Gastrointestinal: No nausea, vomiting, diarrhea, constipation.
Endocrine: History DM type 2 which is control via diet and medication. Does not recall l.
Similar to Sample+5 (20)
100 cases in ent ear and throat from air alshams university
100 cases in ent ear and throat from air alshams university
25 Important Cases In Ear Nose Throat | SurgicoMed.com
25 Important Cases In Ear Nose Throat | SurgicoMed.com
APA format in a SOAP Note format. 1 page long with questions as to
APA format in a SOAP Note format. 1 page long with questions as to
CASE PRESENTATION: UPPER RESIRATORY TRACT INFECTION
CASE PRESENTATION: UPPER RESIRATORY TRACT INFECTION
Case presentation Esthesioneuroblastoma Dr Utkal Mishra
Case presentation Esthesioneuroblastoma Dr Utkal Mishra
Student Name Course Name Assignment Due Date Week 3 S.docx
Student Name Course Name Assignment Due Date Week 3 S.docx
Sample+5
- 1. CHIEF COMPLAINT: Ear pain. SUBJECTIVE: Due to history of right ear pain. Some nasal congestion over the past week. No cough. No fever. The appetite is better today. PAST MEDICAL HISTORY: Notable for some current otitis media in the last several years, usually involves both ears. MEDICATIONS: Responds fairly well to amoxicillin. ALLERGIES: No know drug allergies. PHYSICAL EXAMINATION: GENERAL: Nontoxic. HEENT: Left TM is clear. Right TM is bulging, dull, injected with obvious purulent effusion. Eyes are clear. Nose is clear. Mouth and oropharynx are clear. NECK: Supple with mild tenderness on right anterior cervical region. No significantly enlarged lymph nodes. ASSESSMENT: Right otitis media. PLAN: Amoxicillin suspension 500 mg b.i.d. x5 days. Follow up as needed and in several months for 7-year-old well-child check.