This paper will address two presentations, a pediatric patient with ear pain, and an adult with thyroid related problems.Physical Examinations for Assessment Essay

This paper will address two presentations, a pediatric patient with ear pain, and an adult with thyroid related problems.Physical Examinations for Assessment Essay

Patient 1

The first patient is a 2 year old female that presents with her mother. The mother reports the patient is fussy, unwilling to eat, has nasal drainage, and is tugging at her right ear.

After introducing myself, the mother identifies the patient using two identifiers, name and birthdate. The information provided by the mother is verified against the chart and an identifying wristband is applied to the patient. A wristband is applied to the mother as well, to aid staff in identifying the mother as well as the patient. The mother reports that over the past three days, the patient has become increasingly irritable, is not eating well, and is tugging at her right ear. The mother further states that the patient was sent home from daycare because of a low grade fever and nasal congestion. The mother states she has tried giving the patient Benadryl and children’s Tylenol, but it hasn’t helped.Physical Examinations for Assessment Essay

I continue with my interview by asking about the child’s health history and medication allergies. The mother states the child has no allergies and takes no prescription medications. She reports that the child has been healthy, and was a full term, normal birth with no complications.

After obtaining subjective data from the mother, the physical assessment begins. The patient is allowed to sit on the mothers lap. To avoid undue stress to the patient, a focused assessment is performed. The patients vital signs are as follows: heart rate 128 beats per minute, respirations 22 per minute, even and unlabored, 100% oxygen saturation, oral temperature of 99.6, and a weight of 28 pounds or 12.7 kilograms. The patient is observed tugging at her right ear during the assessment. The right ear is examined using an otoscope. The otoscope exam is performed on a child by gently pulling the auricle of the ear downward and backward (Jarvis, 2012). This process will move the acoustic meatus in line with the canal. The otoscope is held like a pen/pencil and the little finger is used as a fulcrum. This prevents injury should the patient turn suddenly. The tympanic membrane erythematous, lacks luster, and is bulging.Physical Examinations for Assessment Essay The cone of light is distorted. The manubrium, and short process of the malleus are difficult to visualize. The left ear is examined and reveals a glistening, translucent non-erythematous tympanic membrane with light reflex extending anteriorly/inferiorly from the umbo. The manubrium and short process of the malleus are well identified. No drainage is noted from either ear. Continuing the assessment, the eyes are clear with no redness or conjunctiva. The pupils are equal and reactive to light. The nares are bilaterally obstructed with clear sinus drainage. The patient has good dentition. Her lips, tongue, oral mucosa, and uvula are unremarkable. The patient’s lungs are auscultated and her respirations are even and unlabored. An apical heart rate of 129 beats per minute is auscultated, with a normal S1 and S2. At this time the patient becomes agitated and the physical assessment is completed.Physical Examinations for Assessment Essay

Summary of findings

The patient has acute otitis media in her right ear, along with sinusitis. Children, especially those ages one to six years are at particular risk for acute otitis media because they have very narrow Eustachian tubes (Jarvis, 2012). Children in daycare are highly prone to getting upper respiratory tract infections, so they tend to get more ear infections as well (Baylor College of Medicine, 2014).Physical Examinations for Assessment Essay

SOAP note

S: The patient’s mother reports irritability, decreased appetite, and tugging at the right ear.

O: The patient is a nontoxic appearing white female child of approximately 2 years of age. The patient is slightly febrile (99.6), sinus drainage is noted from both nares. The right ear shows a tympanic membrane that is erythematous and bulging. The left ear appears healthy. The nares are occluded bilaterally with clear sinus drainage. The mouth and dentition are unremarkable. PERRLA at 3mm noted. Regular apical rate with S1 and S2, no S3 or S4 noted. Respirations are even and unlabored. Lungs are clear to auscultation bilaterally.Physical Examinations for Assessment Essay

A: The patient appears to be suffering from acute otitis media and sinusitis. Because of the child’s age, an RSV (respiratory syncytial virus) specimen is obtained from the nares and sent to the lab. A normal result would be negative. Positive would indicate a viral infection. The lab results are negative for RSV.

P: The patient will be treated with amoxicillin suspension at twenty five milligrams per kilogram divided into two doses per day (Medscape, 2014). This amounts to one hundred fifty eight milligrams e