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Pediatric Case Study

Acute Otitis Media

HISTORY / CHIEF COMPLAINTS: [ ] ASYMPTOMATIC [ ] F/U [x] SICK VISIT

CHIEF COMPLAINT: Allergies: NKDA

 

Current Meds:

 

PHYSICAL EXAMINATION:

Age:

[ ] GENERAL: [ ] No Acute distress [ ] Well hydrated [ ] Playful [ ] cooperative/pleasant

[ ] HEAD: [ ] Normocephalic [ ] macrocephalic [ ] microcephalic [ ] atraumatic

[ ] normal hair distribution

[ ] EYES: [ ] L [ ] R [ ] B [] conjunctiva red/injected [ ] no discharge [ ] discharge present

[ ] EARS: Ear canals: [ ] L [ ] R [ ]B [ ] erythematous [ ] no purulent d/c [ ] purulent discharge

TMs: [ ]L [ ]R [ ]B [ ] erythematous/inflamed [ ] not bulging [ ] bulging

[ ] NOSE: [ ] congested nasal passages bilaterally

[ ] PHARYNX: [ ]   TONSILS: [ ] erythematous/inflamed [ ] enlarged

[X] no exudates [ ] no cervical lymphadenopathy

[ ] LUNGS: [ ] scattered rhonchi [ ] no rales [ ] no wheezing [ ] rales present [ ] wheezing

[ ] HEART: [ ] regular rhythm [ ] rate normal [ ] bradycardia [ ] tachycardia [ ] no murmur

[ ] ABDOMEN: [  Flat [ ] Distended [ ] BS normoactive [ ] BS increased [ ] BS decreased

[ ] shifting dullness [ ] epigastric tenderness [ ] periumbilical tenderness [ ] suprapubic tenderness [ ] RUQ/RLQ/ LUQ/LLQ tenderness [ ] hepatosplenomegaly

 

ASSESSMENT:

 

PLAN:

 

References:

AT LEAST 3 REFERENCES

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