Assessment
Otitis media is an ear infection that produces inflammation in the middle ear. The majority of middle ear infections result from a buildup of mucus in the middle ear caused by an infection such as a cold. Signs and symptoms include fever, being sick, and earache. In younger kids, signs that the baby has an ear infection include rubbing or pulling the ear, fussiness, lack of appetite, and sings of difficulty hearing. This is the primary diagnosis that the patient has otitis media since it represents most of the symptoms of otitis media and the severe bilateral bulging tympanic membranes seen on the exam (Mayo clinic, 2021).
Pharyngitis is the most frequent cause of acute pharyngitis in children is a virus, but there can be bacterial cause, as well. Viral pharyngitis can go away on its own (Dunphy et al., 2019). The signs and symptoms include pain, swelling, and redness of the throat.
Influenza is a viral infection that has an impact on the lungs’ airways. Signs and symptoms include sore throat, fever, running nose, and body ache. I ruled this out since the patient has negative test results.
Croup iscommon in children between the age of 6 months and 3 years, and is caused by a virus. The main signs of croup are seals bark cough and laryngitis, which are not related to our patient.
Final Diagnosis: Otitis media
Plan
Pharmacology
Amoxicillin 80-90mg/kg/day in 2 divided dose for 10days
Acetaminophen 160 mg/5ml- 5ml every 4-6 hours as needed
Non-Pharmacology
Increase fluid intake
Clean humidifier
Cool mist vaporizer
Saline nasal spray
Diagnostics
Otoscopy during physical examination
Consults/Referrals
No referral needed
Patient education
Mother must be advised to keep the child’s vaccination up to date
Hand hygiene
Avoid smoking and tobacco use in front of the child
Importance of taking antibiotics on time for 10 days
Side effect of amoxicillin can cause diarrhea
Call the doctor if the child has allergic reaction which can cause skin rash, problems with swallowing, shortness of breath, or swelling of the face, hands, or mouth.
Follow Up
Whether or not antibiotics were recommended, your son’s symptoms should get better in 24 to 48 hours. Call your doctor or nurse for help if your child’s condition does not improve within 48 hours, or worsens at any time.
Even if your son may still have a fever and fussiness after taking antibiotics, his conditions should get better every day.
Contact the healthcare provider as soon as you can if your child seems sicker than before when he saw the pediatrician.
References
Johns Hopkins Medicine. (2022). Influenza. Retrieved January 11, 2023, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/influenza
Mayo Foundation for Medical Education and Research. (2021). Ear infection (middle ear). Mayo Clinic. Retrieved January 10, 2023, from https://www.mayoclinic.org/diseases-conditions/ear-infections/symptoms-causes/syc-20351616
Pelton, S., & Tähtinen, MD, PhD, P. (22AD). Otitis Media. UpToDate. Retrieved January 11, 2023, from https://www.uptodate.com/contents/ear-infections-otitis-media-in-children-beyond-the-basics
U.S. National Library of Medicine. (2022). Amoxicillin: Medlineplus Drug Information. MedlinePlus. Retrieved January 11, 2023, from https://medlineplus.gov/druginfo/meds/a685001.html
Wolford RW, Goyal A, Belgam Syed SY, et al. Pharyngitis. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519550/
Value: 100 points
Due: 7
Gradebook Category: Assignments—iHuman Assignments
Introduction
The iHuman platform is an opportunity for you to interact with a simulated patient and gather data. When working in iHuman, practice as if this were a real patient. For example, the platform allows you to ask several questions when taking a patient history. In real life, you likely will be limited in time. Practice setting yourself a patient history time limit and work on being efficient in your clinical interview.
If you require technical support with the iHuman platform, use the iHuman Help Center to contact iHuman Technical Support directly. Technical support only includes a malfunction of the platform; they cannot help with issues involving content!
Instructions
In this assignment, you will review a patient scenario in iHuman. Please see the course announcement for the case assigned this week. Your deliverable for this assignment is a paper based on the iHuman Soap Note Template (Word).
Follow the requirements listed in the iHuman Soap Note Template.
When your iHuman Soap Note Template is complete, upload it to this assignment.
All papers must conform to the most recent APA standards.
Please refer to the Grading Rubric for details on how this assessment and plan is graded.
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Submission statusSubmitted for gradingGrading statusGradedTime remainingAssignment was submitted 10 hours 15 mins earlyLast modifiedSunday, 15 January 2023, 1:40 PMFile submissionsWeek 2 Ihuman .docxTurnitin ID: 19930799437%15 January 2023, 1:40 PMSubmission commentsComments (0)
