wk5assignpost.docx - CASE STUDY 3 Subjective Chief Complaint(CC CS#3 Ear pain History of Present Illness(HPI 11-year old Caucasian male present to the

wk5assignpost.docx - CASE STUDY 3 Subjective Chief...

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CASE STUDY 3: Subjective: Chief Complaint (CC): CS#3 Ear pain History of Present Illness (HPI): 11-year old Caucasian male present to the clinic with Grandmother for a complaint of right Otalgia for the past two days. The patient describes the pain as throbbing, accompanied by “feeling warm,” “spinning room,” ear drainage, and hard of hearing: patient rate pain 4/10, no OTC medication is given. Grandmother tried to clear ear with a cotton swab to
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see if that would help, no relief. Medications: daily vitamin Allergies : sulfur (rash) Past Medical History (PMH): grandmother reports frequent ear infections as a child. Age one. Denies past surgeries, injuries, Family history- The patient’s mother has HTN and hx. of ear infections as a child. According to Dains, Baumann, and Scheibel (2019), having a sibling or parent with chronic otitis hx. makes it twice as likely for the illness to develop in the child. Father unknown, maternal grandmother-Hyperlipidemia, DM, HTN. No other medical conditions reported in the family Social history-CJ is a fifth-grade male who lives with mother and grandmother who cares for the child while the mother is at work. CJ is on summer break and enjoys swimming3-5 days per week, playing sports but denies injury or recent trauma to ear, and listening to music. English is primary language and learning Chinese. ROS: Genera l-denies fever but grandmother reports patient feeling warm, patient denies chills, weight loss, and fatigue. HEENT: Denies headache, reports head pressure when he tried to lie down, reports dizziness, denies head injury, and LOC. Denies eye pain, blurring, double vision, visual changes, glasses, trauma. Reports right ear pain 4/10, Erythema, reports muffled hearing in the right ear, + clear discharge from the right ear, + pruritic to the right ear, + vertigo, tinnitus. Denies nasal drainage, denies congestion, denies polps, denies sinus infection, denies nose bleeds. Denies sore throat, denies hoarseness, ulcers, bleeding gums, gingivitis, and tooth problems.
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