Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning.
Colleague's Post
CC: “Earache in right ear”
HPI: The patient is an 11-year-old Caucasian male brought in by grandmother after complaining of having a mild earache for the past two days. He states that pain was worse when falling asleep and that is was harder for him to hear. Grandmother believes patient feels warm but has not taken temperature.
Medications: Patients does not take any medications
Allergies: No known allergies
PMH: Bronchitis at age 8. Immunizations up to date. Flu shot received.
FH: No family history of ear disease. Younger brother diagnosed with Tourette syndrome since age 5. Patient lives with mother, younger brother, grandmother, and grandfather in the same household.
SH: Student at a public elementary school. Currently on summer break. Grandmother reports that patient has been spending a lot of time in the pool, almost daily. Will occasionally go out with friends but prefers being in the pool.
ROS:
General: Negative for chills, fatigues. Positive for fever.
HEENT: Positive for right ear pain and mild hearing loss. Denies tinnitus. No changes in vision. Denies eye pain. Has not had any episodes of epistaxis. No history of nasal polyps or recent sinus infections. Last dental exam 6 months ago; no lesions, gum bleeding, or dental appliances.
O.
VS: BP 110/78; P 92; T: 99.4F orally; O2 99% RA, Wt 110lbs; Ht 60”
General: AAOx4, appears mildly uncomfortable, holding head to right side slighty
HEENT: Head is normocephalic without signs of trauma. PERRLA, EOMI, oronasopharynx is clear. Pain with movement of pinna. Right tympanic membrane obscured/thickened, ear canal is red with watery discharge that is foul-smelling. No complains of sore throat. No redness in throat.
Skin/Neck: Prominent tan. Warm and dry; good skin turgor. No edme, clubbing, or cyanosis; no palpable nodes.
Neurological: No complains of headaches or dizziness
Diagnostic results: Mild elevated temperature (99.4F oral); elevated WBC 12,000
A.
Differential Diagnosis
Acute External Otitis
Acute Otitis Media
Otitis Media with Effusion
Foreign Body or Cerumen Impaction
Barotrauma
P. Section is not required for the assignments in this course.
Primary diagnosis/presumptive diagnosis: acute otitis media
Ear pain is a problem that frequently occurs in both children and adults caused by an inflammatory process. The presumptive diagnosis for the 11-year-old boy complaining of ear pain is acute otitis media. Acute otitis media was chosen as a possible diagnosis because the patient presented with a fever, conductive hearing loss and a red tympanic membrane. With acute otitis media, an individual can present with fever, earache that interferes with sleep, foul smelling discharge, conductive loss as the middle ear fills with pus, and a tympanic membrane with distinct erythema (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Diagnostic studies are not needed for this diagnosis but the use of an otoscope will be needed to inspect the external auditory canal and middle ear. The 11-year-old presents with most symptoms associated with acute otitis media because he has pain that interrupts his sleep, his ear canal is red, has conductive hearing loss, and has a foul-smelling odor upon inspection of his right ear.
Acute external otitis was also chosen as a possible diagnosis because it initial symptoms often occur after swimming. Acute external otitis is also called ‘swimmers’ ear and can occur when local defense mechanisms become impaired by prolonged ear canal wetness (Hui & Canadian Pediatric Society, Infectious Diseases and Immunization Committee, 2013). According to Ball, Dains, Flynn, Solomon, and Stewart (2015), external otitis’ initial symptoms include itching typically occurring after swimming. Pain is often intense when the pinna is moved and there can be watery discharge that can then become thick and purulent and have a foul smelling-odor. The patient can also report a stuffed ear and conductive hearing loss can occur (Dains, Baumann, & Scheibel, 2016).
Otitis media with effusion is another possible diagnosis that the patient can be given. With this diagnosis, a patient can present with conductive hearing loss as the middle ear fills with fluid, there is discomfort or a feeling of fullness in the ear, and the tympanic membrane may be retracted or bulging. The patient above presents with a few symptoms under this differential diagnosis: hearing loss and discomfort.
Another differential diagnosis is foreign body or cerumen impaction. This diagnosis is a possibility as the patient reports hearing loss and there is a foul-smelling odor upon inspection . With foreign bodies and cerumen impaction, the patient reports a stuffed-up ear or decreased hearing acuity (Dains, Baumann, & Scheibel, 2016). There can also be a foul-smelling ear from drainage secondary to an infection or abscess.
Lastly, another possible differential diagnosis is barotrauma. According to Dains, Baumann, and Scheibel (2016), barotrauma produces an acute serous otitis that is caused by pressure changes. This diagnosis can present with hearing loss, sensation of fullness, retraction or bulging of the tympanic membrane. Since the patient has been in the pool, we don’t know how deep the pool is and need to consider pressure changes from swimming in the water.