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What is appropriate follow-up for this patient?  What would you do if her symptoms do not improve with your initial treatment plan?

What is appropriate follow-up for this patient?  What would you do if her symptoms do not improve with your initial treatment plan?

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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What is appropriate follow-up for this patient?  What would you do if her symptoms do not improve with your initial treatment plan?

CC: She is not sleeping and acts like her ear hurts HPI: 10-mo-old girl, who is scheduled to be seen for an "ear infection." Her mother reports that she was awake a lot during the night. "I think she was pulling at her right ear. Amoxicillin does not work for her." She also reports that last week she had a runny nose and a mild cough treated with Tylenol. Hasn't been eating as well as usual. Baby does not go to daycare, although her mother does meet other mothers and babies in the park on nice days, and they play together. She did that over the past week. She also reports that no one else in the household has been sick. Baby was full term, normal vaginal delivery with good Apgar scores. Still breastfeeding. She has a positive history for an ear infection at age 2 mo (treated with Amoxicillin), at 3 mo (treated with Bactrim), and at 4 mo (also treated with Bactrim). A mild effusion was noted at her 6-mo well child visit, but she was not treated, as she was asymptomatic at that time. Development milestones are within normal limits, and immunizations are up to date. PmHx: otitis media Meds: Acetaminophen OTC q 8 hrs Allergies: NKDA Vital Signs: BP = 104/60 HR = 104 RR = 26 T= 39.1°C Wt = 10 kg Ht = 30" Physical Exam: no abnormalities except both tympanic membrane (TM) erythematous, limited mobility, copious cerumen, purulent fluid, right greater than left, throat is erythematous Labs: None
Transcribed Image Text:CC: She is not sleeping and acts like her ear hurts HPI: 10-mo-old girl, who is scheduled to be seen for an "ear infection." Her mother reports that she was awake a lot during the night. "I think she was pulling at her right ear. Amoxicillin does not work for her." She also reports that last week she had a runny nose and a mild cough treated with Tylenol. Hasn't been eating as well as usual. Baby does not go to daycare, although her mother does meet other mothers and babies in the park on nice days, and they play together. She did that over the past week. She also reports that no one else in the household has been sick. Baby was full term, normal vaginal delivery with good Apgar scores. Still breastfeeding. She has a positive history for an ear infection at age 2 mo (treated with Amoxicillin), at 3 mo (treated with Bactrim), and at 4 mo (also treated with Bactrim). A mild effusion was noted at her 6-mo well child visit, but she was not treated, as she was asymptomatic at that time. Development milestones are within normal limits, and immunizations are up to date. PmHx: otitis media Meds: Acetaminophen OTC q 8 hrs Allergies: NKDA Vital Signs: BP = 104/60 HR = 104 RR = 26 T= 39.1°C Wt = 10 kg Ht = 30" Physical Exam: no abnormalities except both tympanic membrane (TM) erythematous, limited mobility, copious cerumen, purulent fluid, right greater than left, throat is erythematous Labs: None
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