Ears positive for right ear pain and pressure

This preview shows page 2 - 4 out of 6 pages.

Ears:Positive for right ear pain and pressure, tenderness with percussion. Negative for discharge or heaNose:Positive for drainagegross-smelling, tasting, pressure, congestion, and sinus pain. Positive for recsinus infection. Negative for loss of smell.Mouth & Throat:Positive for sore throat at nighttime. Negative for hoarseness or change in voice.Cardiovascular:Negative for chest pain or irregularities.Respiratory:Positive for nighttime cough, and it got worse when laying down. Negative for dyspnea or wheezinNegative for chest painBreasts:No dataGastrointestinal:No dataMusculoskeletal:Negative for joint pain.Peripheral:No dataNeurological:No dataPsychiatric:No dataPhysicalExaminationVital signs:Not assessed.General Appearance:Well-developed Caucasian female sitting comfortably in the chair, which is in no acute distress. Shand cooperative with assessment.HEENT:Head: normocephalic with no indications of trauma. Pain to frontal and maxillary sinuses. Eyes: Conjunctiva clear with no discharge. Ears: Right ear with tenderness and “popping” noise heard on the manipulation of the tragus. Heargrossly intact. Tympanic membranes intact, pearly gray, no erythema, cone of light visualized, neginfection or any issues or no wax. Left tympanic membrane showed scarring, cone of light visualizeNose: Nasopharynx mucosa swollen and with drainage. Throat: Tonsils with purulent drainage.Neck:Not assessedLymph Nodes:Right preauricular lymph node tender. Left preauricular lymph node nontender.Chest:Lung sounds clear to auscultation bilaterally.No wheezes, rales, or rhonchi. Nonlabored breathingaccessory muscle use.Cardiac:S1 and S2 present. Regular rate and rhythm. No murmurs, friction rub, or gallop.Abdomen:Not assessedGenitourinary:Not assessedSkin:Not assessedMusculoskeletal:Not assessed.Neurologic:Alert and orientated x4. Cranial nerves are grossly intact. Speech is fluent. Follows direction approPsychiatric:The mood is appropriate for situation. Thoughts are appropriate, no disordered thinking.
AssessmentPrimary diagnosis:Acute recurrent rhinitisDifferential Diagnosis:1. Chronic Migraine 2. Acute Infectious Rhinitis3. Chronic Rhino sinusitisPlan1.Augmentin 875mg/125mg one pill twice daily by mouth for ten day2.Health Teaching:- OTC sinus wash. Use a home vaporizer to humidify air.- Increase fluid intake- Rest- Tylenol for any aches or pains or fever3.Afrin (pseudoephedrine) nasal spray: 2-3 sprays per nostril everyhours for a maximum of 3 days - decongestantProfessional References to Support the Primary and Differential DiagnosisPhysical examination findings related to acute sinusitis include nasal congestion and obstruction, purulent nasal discharge, maxillary tooth discomfort, facial pain or pressure that is worse or localized to the sinuses, fever, fatigue, cough, hyposmia or anosmia, ear pressure or fullness, headache, and halitosis. At least four of these symptoms should be present (Patel & Hwang, 2018)Chronic daily headache is a descriptive term that encompasses several different specific headache diagnoses characterized by frequent headaches.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture