Comprehensive Case Write-up on a pediatric patient with an ear infection, please include treatment/medication, patient education, and ICD 10 code for each diagnosis primary diagnosis, and differential diagnosis no abbreviation eg cc
Comprehensive SOAP Note
Patient initials: P.R. Age: 6 years Sex: Male Race: Latino
Subjective:
CC: “My son is complaining of ear pain and keeps crying all the time due to the pain. He also complains of hearing difficulty. Yesterday, he had nausea and fever that also came with vomiting.”
HPI:
P.R. is a 6-year-old Latino male boy who has reported to the office accompanied by his mother. His chief complain is ear pain and persistent crying. The child further reports hearing difficulties. As reported by the mother, P.R. had nausea and fever that also came with vomiting yesterday. Additionally, he pulls and rubs his ears whenever he is in pain. Since the symptoms began 7 days ago, P.R. has lost appetite and is unable to play with his friends. From the child’s reactions, one can conclude that the he is experiencing severe pain. According to his mother, P.R. has been using paracetamol to manage the pain. However, the drugs have not helped him much. The pain is triggered by cold weather and it subsides when the weather is hot. The mother indicates, that P.R. had his last physical exam 12 months ago.
Past Medical History: P.R. has been treated severally for cold and flu in the past few weeks. He was successfully treated for pneumonia when he was 2 years old. As documented in his medical records, P.R. has been receiving his vaccines according to schedule. He is up to date with polio, diphtheria, pertussis, and tetanus (DPT), and measles, mumps, rubella (MMR) vaccines.
Past Hospitalizations: P.R. was hospitalized at the age of 2 years due to pneumonia complications. He stayed in the hospital for 7 days.
Past Surgical History: P.R. has never undergone a surgical operation in his lifetime.
Medications: P.R. is currently using paracetamol which the mother bought from a nearby chemist shop. He is taking 5 ml syrup 3 times per day.
Allergies: P.R. is allergic to dust which makes him cough a lot. His mother denies food or drug allergies.
Social History: P.R. receives immunization as part of his health promotion strategies. P.R. lives in town wit his parents and two siblings aged 1 and 3 years respectively. He is in kindergarten. The family does not have any pets at home. His parents do not consume alcohol or cigarettes. The boy’s father works as an accountant while his mother is unemployed. The mother remains with he two siblings at home when P.R. goes to school. P.R. likes to play football with his friends in the neighborhood. However, he has not been playing with them since the current symptoms began.
Family History: P.R.’s grandparents are alive. His paternal grandfather and grandmother are 68 and 62 years old respectively. His maternal grandfather and grandmother are 63 and 58 years old respectively. The boy’s father and mother are 38 years and 32 years respectively. Neither his grandparents nor his parents have been diagnosed with a serious medical condition. P.R.’s siblings are healthy.
Birth History: P.R.’s mother gave birth to him through normal delivery at 41 weeks gestation. The mother states that the onset of labor was spontaneous. She denies having serious complications during pregnancy. However, she reports mild symptoms such as cold that disappeared without treatment. P.R. was in good health at the time of birth.
Review of Systems (ROS):
General: Reports nausea, fever, and vomiting. Reports pain in the left ear. Report loss of appetite.
Skin/nails: Denies abnormal skin lesions. Denies brittle nails. Does not report skin rashes or bruising.
HEENT:
Head: Denies a recent traumatic head injury. Does not report a headache. Denies alopecia. Denies using contact glasses. Denies vision issues. No excessive tearing or double vision reported. Reports ear pain, hearing difficulties, and ear rubbing. Denies nasal stuffiness. No nasal obstruction or discharge reported. The boy has changes in appetite as reported by the mother. Denies mouth dryness or ulcers, pain, or dryness. Denies issues with the throat.
Neck: Does not report goiter. Denies neck pain.
Lymphatics: Denies swollen lymph nodes.
Breasts: Denies discharge, pain, or lumps on both breasts.
Pulmonary: Denies breathing difficulties. Denies wheezing. Reports a history of pneumonia.
Cardiovascular: Does not report shortness of breath, chest pain, or tightness of the chest. Denies a history of high blood pressure or cardiovascular conditions.
Gastrointestinal: Denies abdominal pain or diarrhea. Reports vomiting, nausea, and loss of appetite. Denies heartburn or bloating.
Urinary: Does not report hematuria. Does not report changes in urination frequency. Denies nocturia.
Genital tract (male): Denies issues with genital organs.
Musculoskeletal: Does not report limitation with movement. Does not report joint pains or stiffness. Denies joint tenderness, joint swelling, backache, or a history of bone fractures.
Neurologic: Does not report a headache. Denies dizziness. Reports severe ear pain.
Psychiatric: Reports reduced interest in playing with other children. Does not report nervousness. Reports difficulty falling asleep due to severe ear pain.
Endocrine: No heat or cold intolerance reported. Denies abnormal night sweats. Does not report excessive hunger. Denies abnormal changes in urine volume.
Hematologic: Denies uncontrolled bleeding or blood-related disorders such as anemia and sickle cell disease.
Objective
Vital signs: Temperature: 101oF, blood pressure: 113/63, respiratory rate: 19 breaths per minute, weight: 44 pounds, height: 115 centimeters, BMI: 15.kg/m2 (65th percentile).
General appearance: Ear pain is causing P.R. a lot of discomfort. The boy keeps crying due to the ear pain. However, he is neatly dressed and well-groomed.
Skin: Warm and without rashes. No sores or lesions are observed on the skin.
HEENT:
Head: Normocephalic with no evidence of physical injury. No masses. No alopecia. No evidence of hair thinning.
Eyes: Opacified cornea. Clear conjunctivae, non-icteric sclerae. Visual acuity is 20/20.
Ears: Both pinnae are visible. Ear canal is tender and edematous. No discharge is observed on the ear canal. There is no evidence of blockage. Dark-pink tympanic membrane.
Nose: Absence of enlarged turbinates. No evidence of nasal tenderness. Moist and hairy nasal mucosa.
Throat: No evidence of sores or lesions in the oral mucosa. Non-erythematous throat. Absence of tonsillar exudates or edema.
Neck: No abnormal pulsations or masses. No evidence of swelling or pain.
Nodes: Absence of swelling or pain in the lymph nodes.
Breasts: No tenderness, abnormal masses, or discharge in both breasts.
Chest: No rhonchi rubs or wheezes.
Heart: Capillary refill less than 3 seconds. No murmur, no gallop.
Abdomen: Abdominal tenderness is absent. No bowel sounds heard. Abdominal scars absent.
Back/spine: Absence of curvature. No deformities observed.
Extremities: No evidence of pain or tenderness of the joints.
Genitalia/Rectal: Growth and development stage of genital organs are appropriate for the boy’s age.
Neurologic: Normal speech. No evidence of muscle rigidity. Normal gait.
Laboratory data: No laboratory or diagnostic tests have been ordered so far.
Assessment
Differential diagnoses:
- Acute otitis media (presumptive or primary diagnosis)
ICD 10 code: H66.90-Acute otitis media
- Otitis media with effusion
ICD 10 code: H65:91-Otitis media with effusion
- Tympanic membrane perforation
ICD 10 code: H72.90-Tympanic membrane with perforation
Rationale
Acute Otitis media (presumptive or primary diagnosis)
Acute otitis media has been chosen as the primary or presumptive diagnosis for the patient. The reason is that the patient’s subjective and objective data match closely with symptoms of acute otitis media. For example, the condition is commonly diagnosed in children. The patient being evaluated is a child aged 6 years old. Again, the specific symptoms for the disease that are present in the boy include; ear pain, persistent crying due to the discomfort caused by the pain, fever, vomiting, rubbing of the eat, hearing difficulties, and loss of appetite (Wijayanti et al., 2021). Therefore, acute otitis media fits best as the boy’s presumptive or primary diagnosis.
Otitis media with effusion
Symptoms of otitis media with effusion closely resemble those of acute otitis media. However, an additional symptom in affected children is usually a yellowish discharged from the affected ear (Merchant & Neely, 2021). In this respect, otitis media with effusion has not been selected as the presumptive or primary diagnosis for the patient because there is no evidence of yellowish discharge from the ear.
Tympanic membrane perforation
Another possible diagnosis based on the patient’s symptoms is tympanic membrane perforation. Acute pain, hearing difficulty, fever, and itching are common symptoms of tympanic membrane perforation. Additional symptoms include fluid discharge from the ear and tinnitus or ringing of the ear (Ghimire et al., 2022). Although the patient presents with some of these symptoms, he does not report tinnitus or fluid discharge from the ear. The absence of these pertinent positive symptoms of tympanic membrane perforation in the patient explain why the condition has not been chosen as his primary diagnosis.
Plan for the Primary Diagnosis
Diagnostic test ordered:
- Otoscopy: Examines the middle ear. The presence of a bulging tympanic membrane confirms the presence of acute otitis media (Schilder et al., 2017).
Medications ordered:
- Continue acetaminophen 5 ml 3 times per day.
- Amoxicillin antibiotics- 80mg/kg twice daily for 10 days (Spoiala et al., 2021)
Patient education/teaching and anticipatory guidance:
- The patient should use the medication as prescribed.
- The mother should monitor the patient for any drug reactions or side effects and inform the clinic immediately (Hullegie et al., 2021).
Health maintenance:
- It is important to keep the ear clean to enhance recovery.
- The child should be taught to avoid pricking or scratching the ear with a sharp object (Leach et al., 2021).
Referrals:
- No referrals are necessary at this point. However, when the patient fails to respond to the prescribed medications, he should be referred to an otologist for further assessment and treatment (Spoiala et al., 2021).
Follow-up Plan:
- Visit the clinic after 4 weeks for evaluation and further guidance (Leach et al., 2021).
Billing Code
- CPT: 99203 (American Academy of Pediatrics, 2021).
References
American Academy of Pediatrics. (2021). Revisions to pediatric office-based evaluation and management coding: 2021 revisions. https://www.aap.org/globalassets/publications/errata/ma1010-errata.pdf
Leach, A. J., Morris, P. S., Coates, H. L., Nelson, S., O’Leary, S. J., Richmond, P. C., Gunasekera, H., Harkus, S., Kong, K., Brennan-Jones, C. G., Brophy-Williams, S., Currie, K., Das, S. K., Isaacs, D., Jarosz, K., Lehmann, D., Pak, J., Patel, H., Perry, C., Reath, J. S., … Torzillo, P. J. (2021). Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations. The Medical journal of Australia, 214(5), 228–233. https://doi.org/10.5694/mja2.50953
Ghimire, B., Basnet, M., Aryal, G. R., & Shrestha, N. (2022). Tympanic membrane perforation among patients presenting to department of otorhinolaryngology of a tertiary care hospital: a descriptive cross-sectional study. JNMA; Journal of the Nepal Medical Association, 60(247), 246–249. https://doi.org/10.31729/jnma.7269
Hullegie, S., Venekamp, R. P., van Dongen, T., Mulder, S., van Schaik, W., de Wit, G. A., Hay, A. D., Little, P., Moore, M. V., Sanders, E., Bonten, M., Bogaert, D., Schilder, A. G., & Damoiseaux, R. (2021). Topical or oral antibiotics for children with acute otitis media presenting with ear discharge: study protocol of a randomised controlled non-inferiority trial. BMJ Open, 11(12), e052128. https://doi.org/10.1136/bmjopen-2021-052128
Merchant, G. R., & Neely, S. T. (2021). The influence of otitis media with effusion on middle-ear impedance estimated from wideband acoustic immittance measurements. The Journal of the Acoustical Society of America, 150(2), 969. https://doi.org/10.1121/10.0005822
Schilder, A. G., Chonmaitree, T., Cripps, A. W., Rosenfeld, R. M., Casselbrant, M. L., Haggard, M. P., & Venekamp, R. P. (2016). Otitis media. Nature Reviews. Disease Primers, 2(1), 16063. https://doi.org/10.1038/nrdp.2016.63
Spoială, E. L., Stanciu, G. D., Bild, V., Ababei, D. C., & Gavrilovici, C. (2021). From evidence to clinical guidelines in antibiotic treatment in acute otitis media in children. Antibiotics (Basel, Switzerland), 10(1), 52. https://doi.org/10.3390/antibiotics10010052.
Wijayanti, S., Wahyono, D. J., Rejeki, D., Octaviana, D., Mumpuni, A., Darmawan, A. B., Kusdaryanto, W. D., Nawangtantri, G., & Safari, D. (2021). Risk factors for acute otitis media in primary school children: a case-control study in Central Java, Indonesia. Journal of Public Health Research, 10(1), 1909. https://doi.org/10.4081/jphr.2021.1909