Subjective Data

Julia, 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 occasional relieved with the use of over-the-counter pain relievers. Julia has not had any vomiting or diarrhea. She has had a slight runny nose, but no cough.

Past medical history: Julia was born via vaginal delivery at 40 weeks' gestation. She has not had any injuries or illnesses. Her developmental screening was within normal limits at last provider visit.

Social history: Julia lives at home with both parents. Her mother works as a teacher and her father is a commercial fisherman. The family has a pet cat. Julia's father smokes a pack of cigarettes a day.

Family medical history: Unremarkable

Medications: Julia is currently taking Tylenol for the fever and ear pain.

Immunizations are up to date

Allergies: Penicillin (rash, itching and tongue swelling)

Objective Data

Julia is alert and quiet, sitting on her mother's lap. She appears well hydrated and well nourished. Vital signs: temp 100 (axillary), HR 100, resp 26, wt. 14 kg.

Skin: Warm and dry to touch and free of lesions.

HEENT: Head is atraumatic and normocephalic. Pupils are equal, round and reactive to light and accommodation. There is not 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 exam, 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.

Neck: Supple with good range of motion. There are some shotty lymph nodes noted on the left side of neck. There is no erythema or tenderness of the nodes.

Resp: Breath sounds bilateral equal and clear to auscultation. Good rise and fall of rib cage. No retractions noted.

Cardiovascular: RRR no murmurs, rubs or gallops noted.

Abd: Soft, flat, non -tender to palpation. Bowel sounds present in all four quadrants. No hepatosplenomegaly present.

Please include the following:

Diagnosis (rule in)

Differential diagnosis ( rule out)

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

Does the patient's psychosocial history affect how you might treat the case?

What if the patient lived in a rural setting?

Are there any demographic characteristics that might affect this case?

Are there any standardized guidelines that you should use to assess or treat the case?