MEDICAL MYSTERY_SOAP FOR CHAPTER 11

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MEDICAL MYSTERY FOR CHAPTER 11 HIS STORY Alex was recently sent home from preschool by his teacher. She called his mother and told her that Alex had been crying off and on all morning, and that he did not want to go out to play with the other children. His mother immediately left work to pick him up. As soon as she arrived at the school, Alex ran to her, crying and inconsolable. Once they got home, Alex acted irritable and fussy. He kept crying and pulling at his ear. His mother was worried because there had recently been a child diagnosed with infectious myringitis at his school, but Alex did not have a fever or runny nose. Thinking that he was coming down with a cold, she gave him some Tylenol syrup, which quieted him down. He slept fitfully that night, and when he woke up, he kept crying and pulling on his ears, first one and then the other. His mother decided that a visit to the pediatrician first thing in the morning was in order. By then, Alex also had a low-grade fever. THE EVALUATION When they arrived in my office, Alex could not keep still and would not let me examine him. His mother said Alex was up to date on all his vaccines and had a normal childhood with no illness or complaints. I noticed that he did not have a cough, skin rash, or a runny nose. Nothing pointed to an upper respiratory tract infection. He was irritable, fussy, and now had a low-grade fever. I had to get the nurse to help hold Alex while I examined his throat, eyes, and ears. THE DIAGNOSIS Although Alex was periodically tugging at both ears, I suspected that there was something wrong with just one of them. I knew that earaches usually do not localize, since the nerve from the ear runs close to the center of the mouth. Sure enough, when I finally got a good look at Alex’s left ear, I suspected that he had a bad case of otitis media. Although this inflammation of the middle ear often begins when infections that cause sore throats, colds, or other respiratory or breathing problems spread to the middle ear, it looked to me as if there might be something lodged in Alex’s ear. I gave his mother a referral to an ENT (ear, nose, and throat) specialist and asked that he be seen right away. THE TREATMENT The ENT specialist discovered that there was a small piece of light-colored chalk lodged in Alex’s ear. The ear canal had been blocked, and once the doctor removed the chalk, she could see clear evidence that Alex was suffering from otopyorrhea, an indicator that infection was present. Alex immediately improved after the removal of the chalk, which he apparently had put in his ear at preschool. A 7-day course of antibiotics resolved his condition completely. CASE CLOSED

Two weeks later, I almost didn’t recognize Alex. He was playing contently in the waiting room and seemed happy to come into my office for a tympanometry test. Happily, his ear had returned to normal. Alex’s mother thanked me for the quick diagnosis and asked me how in the world he might have gotten chalk in his ear. I explained to her that children sometimes place things in their ear canal because they are bored, curious, or copying other children. Any child with an irritated and chronically draining ear should be evaluated for the possible existence of a foreign body. Discussion Questions 1. What is otitis media? Otitis media is an inflammation of the middle ear. 2. Define otopyorrhea . Otopyorrhea is the flow of pus from the ear. 3. Why would infectious myringitis be of concern in a preschool? Infectious myringitis would be a concern in a preschool because it is a highly contagious infection that causes blisters on the eardrum. 4. What would tympanometry be used to measure? Tympanometry would be used to measure disorders of the middle ear.

SOAP NOTE CHAPTER 11 Golden Years Senior Clinic 8/22/16 Kerry Young, NP Mrs. Agatha Beard SUBJECTIVE ▪ Reports dry eyes and difficulty “seeing out of the corners of my eyes the way I used to” over several months ▪ Reports occasional floaters in visual field ▪ Denies eye pain ▪ Denies difficulty performing daily tasks due to vision OBJECTIVE ▪ 87-year-old female ▪ Decreased peripheral vision on visual field testing ▪ Tonometry shows increased intraocular pressure ASSESSMENT ▪ Open-angle glaucoma ▪ Xerophthalmia PLAN ▪ Schedule laser trabeculoplasty ▪ Recommend eye drops to help with xerophthalmia Questions 1. How does laser trabeculoplasty work? Laser trabeculoplasty works by creating openings in the trabescular meshwork, allowing the proper drainage of fluid. 2. Define xerophthalmia and provide the word parts. Xerophtalmia is the dry eye due to a decreased production of tears by tear glands. The word parts are xer (meaning dry) and ophthalmos (meaning eye). 3. If the patient had lost vision at the center of her visual field, instead of the periphery, what disease might be the cause? The disease that might be the cause is macular degeneration.

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