NR 511 WEEK 2 CLINICAL PRACTICE GUIDELINE

NR 511 WEEK 2 CLINICAL PRACTICE GUIDELINE

NR 511 Week 2
Paddy Smith- Age 4 years, male Caucasian, insurance (?)
C.C. “Ear really hurts” has popping stuffy feeling
S.
HPI: Patient presents with left ear pain and popping and feeling stuffy; recently had a cold. This morning
woke up with stabbing ear pain that is constant a 3/5 on Wong Baker visual pain scale. States pain is
worsened at night laying down and oral Tylenol improves pain somewhat.
Onset: this morning
Location: left ear
Duration: constant
Characteristics: stabbing ear pain
Aggravating factors: worse when laying
down Relieving factors: OTC Tylenol
Treatment: has only tried OTC Tylenol
Severity: 3/5 on Wong Baker visual pain scale
Current Medications: Daily children’s multivitamin + iron; no prescription medications
Allergies: NKDA; food allergies (?), environmental (?)
PMH: Full term NSVD twin gestation 5lbs 2oz.
Immunizations: not specified
Illnesses: none
Surgical History: none
Hospital Stays: not specified
Social History: Attends half day 4K program, doing well and likes school, lives with mother and father;
both work full time, two older siblings (boy age 9, girl age 7), maternal grandparents, and 2 dogs and
a cat.
Sexual History: N/A
Family History: Mother healthy. Twin brother no significant medical history. Older siblings,
Father, Grandparents- medical history not specified

ROS:

CONSTITUTIONAL: No fever

HEENT: Head: no headache; Eyes: not specified; Ears: Stabbing pain in left ear 3/5, denies hearing loss or
ringing in ears. Nose: denies nasal congesting or discharge; Throat: denies sore throat, difficulty
swallowing. Neck: denies enlarged lymph nodes

SKIN: not specified

CARDIOVASCULAR: denies chest pain, palpitation, or dizziness

RESPIRATORY: denies SOB or

wheezing GASTROINTESTINAL: not

specified GENITOURINARY: not

specified NEUROLOGICAL: not

specified

, MUSCULOSKELETAL: not specified
HEMATOLOGIC: not specified
LYMPHATICS: not specified
PSYCHIATRIC: not specified
ENDOCRINOLOGIC: not specified
ALLERGIES: NKDA
O.
CONSTITUTIONAL: Cooperative, talkative, and appropriate young male who appears his age in no acute
distress.
H- 105cm (41.3 in.), W- 17 kg (37.4lbs) BMI: 15.4 (46th percentile), BP- 102/60, P- 94, R- 18, Sp02- 99%, T-
99.9 (Tylenol one hour before exam)
HEENT: Head: Normocephalic, hair thick and distributed throughout scalp Eyes: Conjunctiva clear, non-
icteric, PERRLA, OEMs intact. Ears: Right ear; tympanic membrane intact with light reflex noted. Left
ear; tympanic membranes intact, red and bulging, no drainage noted in canal. Pinna/tragus w/o
tenderness bilaterally. Nose: Nares patent and unremarkable; Throat: Pharynx with clear drainage
noted, tonsils 2/4 bilaterally. No loose teeth.; Neck: supple, lymphadenopathy noted in preauricular
and posterior cervical nodes, non-tender. Thyroid midline.
SKIN: not specified
CARDIOVASCULAR: not specified
RESPIRATORY: respirations
unlabored
GASTROINTESTINAL: Abdomen sl. rounded with active bowel sounds, soft, non-tender, no masses or
organomegaly
GENITOURINARY: not specified
NEUROLOGICAL: not specified
MUSCULOSKELETAL: not
specified HEMATOLOGIC: not
specified LYMPHATICS: not
specified PSYCHIATRIC: not
specified ENDOCRINOLOGIC: not
specified ALLERGIES: NKDA
A
Primary DX: Acute Otitis Media left ear (H66.002)
Rational for DX- Inflammation of the middle ear caused by viruses or bacteria. (Rosenfeld, 2016). The
most common bacteria and viruses are Streptococcus pneumoniae (pneumococcus), Hemophilus
influenzae, Pseudomonas, and Moraxella which account for about 85% of cases of acute otitis media
(Rosenfeld, 2016). Signs or symptoms of otitis media include: feeling of fullness in ear, ear pain, fever,
irritability, hearing loss, and sleeplessness (Rosenfeld, 2016). Paddy exhibited S & S of feeling of ear
“Stuffiness” and had ear pain and is also getting over a recent cold.
P
Medications:
Continue daily Multivitamin with iron

RX- Amoxicillin oral suspension 400mg/5ml (Amoxicillin, 2016)

Sig- 9.6ml po BID x 5 days