Ibrahim, a 10 year-old Saudi boy presents with his father (Dad) for c/o R ear pain x 3 days. He denies having had a headache, n/v/d/c, abdominal pain, or burning or pain with voiding. Denies
Ibrahim, a 10 year-old Saudi boy presents with his father (Dad) for c/o R ear pain x 3 days. He denies having had a headache, n/v/d/c, abdominal pain, or burning or pain with voiding. Denies cough, sore throat, runny nose, or sinus pain. Denies rash. Dad states he doesn’t think his son had a fever as “he never felt warmer than usual” and did not complain of chills. Dad is concerned that his son caught something when they were swimming in the Red Sea in the Farasan Islands. Dad reports they flew home 4 days ago. Dad states neither of Ibrahim’s two siblings, sisters ages 5 years and 7 years, have had similar symptoms. Dad states Ibrahim has had ear infections in the past, but the symptoms were different. Ibrahim reports his pain as a 7/10 but improves to a 3/10 when his mom gives him children’s paracetamol, the last dose was taken 6 hours ago. Ibrahim is not on any ongoing prescriptions. He has no ongoing medical problems and was in the 90th percentiles for height and weight at his 10 year check- up 2 months ago. He is up to date on all childhood vaccines. He is in 5th grade at primary school. Ibrahim says he likes school and gets high marks. He plays soccer at school. He lives at home with his parents, 2 sisters, and paternal grandmother in a single family home with full utilities. His mother works as a legal secretary. His father is employed as a regional manager for a restaurant chain. Dad reports Ibrahim had an itchy rash when he took amoxicillin that required diphenhydramine to control. No known food or environmental allergies. Religion: Sunni Islam. VS: T 37.2C, P 88, R 18, BP 102/78.
On physical exam (for pictures, describe what you see as if you are examining the patient):
No enlarged lymph nodes on neck, no mastoid redness, swelling, or tenderness. Conjunctiva without redness or drainage, no lid swelling. No nasal drainage noted. Denies tenderness with palpation over frontal and maxillary sinuses.
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Lung sounds: clear to auscultation all fields, bilaterally. Heart regular rate and rhythm, Abdomen bowel sounds active x 4, soft, non-tender to palpation. Hearing diminished R side to whisper test; intact to whisper test on L. No rash noted on arms or legs.
Ibrahim’s oropharynx: Movement is symmetrical and full (uvula is not actually enlarged, it the way I took the picture; white spots on patient’s right are just light reflex from the camera)
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