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Advanced Health Assessment -Patient Case for Head/Neck

Advanced Health Assessment -Patient Case for Head/Neck

Advanced Health Assessment -Patient Case for Head/Neck

QUESTION
reply to RAMANDEEP’s POSTING:
Review the documented subjective and objective history. Provide scholarly support to identify a differential diagnosis based on the reported findings. Include additional subjective or objective data that would support this diagnosis.

Room 1: 2yo Richie is brought to the clinic by his mother Rachel Regis for nasal congestion and tugging at his left ear

HPI: Richie is brought to the clinic by his mother, Rachel Regis, for nasal congestion, tugging at his left ear, and irritability and fussiness, especially at night when she lays him down in his crib. Mom states that Richie is in daycare 4 days per week and there have been a number of other children out sick in the last couple of weeks. Mom also reports Richie uses a bottle at night to go to sleep, but he refused to take it last night. Mom states she has been seeing discharge from his ear. Mom states she uses Q-tips to clean Richie’s ears. Mom states this same problem occurred last year as well and this is the second time it is happening.

PE: T: 100.3 tympanic, HR: 130 apical, RR: 27, 02: 99%. On inspection with an otoscope, amber colored drum without light reflex noted. Minimal movement of tympanic membrane with pneumatic otoscopy. Tenderness noted during palpation of the mastoid process. Both ears are symmetrical upon inspection. Tympanic membrane is red and bulging. Opaque yellow discharge noted upon examination.

The most important thing to keep in mind when assessing small children, is to have their parents with them to make them feel as comfortable as possible. Letting the child sit in the parents lap can help to relieve some of their stress and make them open to the provider examining them (Drutz, 2020). Upon assessment of the ear, the color of the tympanic membrane can play a role in narrowing down possible causes of the problem. A normal tympanic membrane is translucent pale gray in color (Waseem, 2020). The variations in color can be representative of different disease conditions, they can include colors ranging from opaque yellow, blue, dark red, dark pink or lighter red (Waseem, 2020). However, in aiding in diagnosis, the color of the eardrum plays a less important role than the position and mobility of it (Waseem, 2020). For example, redness of the tympanic membrane can be due to other things than a middle ear infection, these include vigorous nose blowing or fever (Waseem, 2020).

Examination of the ear is a crucial skill for healthcare professionals to have as it can help identify various pathologies from common and benign to rare and life-threatening (Hogan & Tadi, 2020). There are certain things the provider has to be able to understand and distinguish. For example, vertigo, tinnitus, hearing loss, popping sounds, discharge from the ear, complaints of earache, associated fever, sore throat, cough are all things the provider has to pay attention to (Bickley, 2017). In the nasal examination, the anterior portion of the nose is seen by using the large speculum on the otoscope, while the nasal mucous membranes are examined for their color and condition (Bickley, 2017).

Acute otitis media (AOM) is the most frequently diagnosed illness in children, and commonly requires antimicrobial treatment (Paul et. al., 2017). Otitis media with effusion (OME), is a disease condition which is often misdiagnosed as AOM, but it does not require antibiotics (Paul et. al., 2017). Diagnosis can be challenging for providers, as both of the conditions present with symptoms like fever, ear pain, and irritability (Paul et. al., 2017). This has led to over-diagnosis of AOM, and the subsequent increase in antibacterial treatment, which has led to an increase in antimicrobial resistance in the pediatric population (Paul et. al., 2017). In this way, it can be seen how the lack of training in the HEENT examination can lead to misdiagnosis and further problems down the road.

References

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking (12th ed.). Wolters Kluwer

Drutz, J. E. (2020, September 01). The pediatric physical examination: HEENT. Retrieved October 07, 2020, from https://www.uptodate.com/contents/the-pediatric-physical-examination-heent

Hogan, C. J., & Tadi, P. (2020, March 11). Ear Examination. Retrieved October 07, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK556014/

Paul, C. R., Gjerde, C. L., McIntosh, G., & Weber, L. S. (2017, August 29). Teaching the pediatric ear exam and diagnosis of Acute Otitis Media: A teaching and assessment model in three groups. Retrieved October 07, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574227/

Waseem, M. (2020, March 09). What color of the tympanic membrane (TM) indicates otitis media (OM)? Retrieved October 07, 2020, from https://www.medscape.com/answers/994656-8234/what-color-of-the-tympanic-membrane-tm-indicates-otitis-media-om
Advanced Health Assessment -Patient Case for Head/Neck

ANSWER
Advanced Health Assessment -Patient Case for Head/Neck
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Response to Ramandeep on Nosal Congestions and tugging in young children

It is vital for children, for their parents to make them as comfortable as possible during treatment and diagnosis. In this case, Richie a two-year-old is brought in by his mother, Rachel Regis with the main complaint of ear tugging and nasal congestion. It is important according to Ramandeep to have Richie’s ear examined, so as to narrow down to the possible diagnosis of the various illnesses that might be affecting Richie.
The initial reaction of tugging and ear pulling might be as a result of accumulated ear wax or even or even a sigh of middle or external ear infection. Although there have been established relationships between teething and ear pulling there is no confirmed link scientifically. According to Ramandeep, the amber ear drum with light colored reflex translated to Acute otitis media (AOM) is common among children and often requires microbial treatment, he further explains the intricacies of the disease, that it does not requires antibiotics (Rosenfeld, 2016).
I agree that this condition might be difficult to diagnose as similar conditions present themselves with fever, ear pain and mostly irritability (Poerbonegoro, 2019). He however warns that this condition does not require anti-microbial treatment, and continuous anti-microbial treatment would lead to a resistance in the young children population of the similar conditions.
I couldn’t agree more with Ramandeep, as the common signs and symptoms are given as pain in the ear, tugging, fussiness, crying more than usual, fever of more than 100 F, Headache as well as loss of appetite. This is explicitly evident when Richie declined to sleep with the bottle. Nosal congestions however might be as a result of acute sinusitis which might be as a result of cold or allergies (Kaur et al., 2017).

References
Kaur, R., Morris, M., & Pichichero, M. (2017). Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Pediatrics, 140(3),
Poerbonegoro, N. (2019). Nasal Congestion and Its Management in Pregnancy Rhinitis. Indonesian Journal of Obstetrics and Gynecology, 318-326.
Rosenfeld, R. (2016). Acute Sinusitis in Adults. New England Journal of Medicine, 375(10), 962-970.

Advanced Health Assessment -Patient Case for Head/Neck

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