Patient Info: Jack is a 7-year-old established patient last…
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Get it written →Patient Info: Jack is a 7-year-old established patient last seen 2 months ago for well child visit. He is accompanied by his mother.
Chief Complaint: “My ear really hurts.”
History of Present Illness: Family has been at Disney World and flew home 2 days ago. Mom reports Jack developed cold symptoms 2-3 days before returning home. Woke during the night, tearful and complaining of right ear pain.
Past Medical History: Environmental Allergies
Recurrent episodes of OM as a toddler
Past Surgical History: Adenoidectomy and myringotomy tubes 2014
Family History: Both parents alive and healthy; 4-year-old brother with asthma
Allergies: Environmental; no drug or food allergies
Medications: Loratadine 5 mg daily; daily multivitamin
Immunizations: Up to date for age
Social History: Lives with parents and brother in a single family home in suburban community. Is a first grader in a community public school where he does well and has many friends. Father is a smoker and tries to smoke outside the home. Mother is stay-at-home mom.
Physical Exam:
Vital Signs: BP: 84/56 HR: 94 RR: 20 Temp: 100.8 Wt: 44 lbs (25th %) Ht: 48″ (50th %)
1. What possible physical exam findings might you see with someone like Jack?
2. What are 3 of Jack’s differential diagnoses, and what 3 things may rule in or out each particular diagnosis?
3. What are at least 5 critical education pieces to share with Jack’s mother?
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