Chief Complain (CC)
CPT CODE assigned was 99392 while the IC-9 CODE assigned was V20.2
The guardian of the patient reported evidence of screaming from pain. Besides, the guarding reported complains like vomiting, irritability and malaise. The body temperature was above 38oC signifying high fever. Other complains noted were reddening and bulging of the eardrum which are vital signs of otitis media(Lieberthal et al., 2013; Pettigrew et al., 2011).
History of Present Illness (HPI)
The guardian reported that the patient was playing with other children and fell down. He started complaining of ear problems. It started with unfamiliar noise that stopped and reoccurred. The family has a father who was smokes and drinks. Besides, the family has a history of ear infections (Pettigrew et al., 2011; Grijalva, Nuorti, & Griffin, 2009).
Last Menstrual Period (LMP- if applicable)
N/A
Allergies
The child is not allergic to antibiotics medications.
Past Medical History
Previously, the child was taken to a general practitioner for examination. Antibiotics were prescribed and administered. The condition has since not changed.
Family History
The family line has previous cases of middle ear infection, which denotes family history to this condition.
Surgery History
No previous surgical operation performed to the patient.
Social History (alcohol, drug, or tobacco use): The child’s father is a frequent smoker but recently stopped drinking.
Current medications: Previously, the patient used oral pain killing agents like paracetamol and ibuprofen in addition to the first line of antibiotics amoxicillin. The required duration for that antibiotic has since expired (30 days). However, the condition has not changed.
Review of Systems
Otitis media occurs in close association with other external infections. Review of systems indicates the patient did not complain of either external otitis or other infections that could present similar symptoms. Besides, dental pains were absent, while temporo-mandibular joint pains did not present during examination. Acute viral pharyngitis was also examined as previously indicated (Lieberthal et al., 2013; Pettigrew et al., 2011).
Objective Data of the patient examination
Tanner stage
The patient was 3 years belonging to tanner stage level 2.
Vital Signs/Height/Weight
Vital signs examined were skin appearance, paleness of the mucous membrane, general weakness and lack of appetite. The measured height was 3.182 ft, while the weight was 17.877 kg (39.412 pounds).
General appearance
The patient general appearance was feeble and worn out. Evident difficulty in coughing was noted during examination. This cough was wet. The patient was sweating. The body temperature was above 38oC signifying very high fever (Zhou, Shefer, Kong, & Nuorti, 2008). Reports of irritability and difficulty in sleeping were also provided by the accompanying guardian.
Heart
This involved evaluation of important vital signs and pulmonary examinations. These included basic observations of the patient’s chest region, palpation of the chest cavity, percussion, and auscultation (Lieberthal et al., 2013). These observations involved paying attention to chest shape, shortness of breath while walking or resting to capture possible abnormalities in the heart. The patients were also assessed for difficulty or ease in sitting upright.
Respiratory system (URTI)
The patient was investigated and examined for rhinosinusitis, pharyngitis as well as acute otitis media based on upper respiratory tract infections. This involved assessing the temperature levels, which was above 38oC signifying fever. Besides, the pulse and respiratory rates were evaluated and found above normal range. Nasal discharge was examined for the presence of color discharge. Obstruction of the nasal was also evaluated and found to be at the level of evidence. Other parameters examined included the enlargement of the tonsils that signified level of evidence. The exudates from the tonsils were very low, while facial tenderness was at the level of evidence. These signs combined with the presence of cough and effusions from the middle ears signified inflammation of the upper respiratory system (Lieberthal et al., 2013; Pettigrew et al., 2011).
Assessment of the patient
Differential Diagnosis
- Patient health history and otoscopy collaborated the absence of otitis external
- The patient was examined for referred pain, which could have originated from the teeth. However, alternative source of primary pain was established from the point of infection.
- Examination of the ear for the presence of foreign body in the external canal revealed absence of any external foreign materials, which could have interfered with the tympanic membrane.
- Trauma was examined around the upper respiratory tract system. Previous reports indicate that patients developed similar conditions after falling down during play. This was not the underlying cause. However, its occurrence could aggravate the condition.
Medical Diagnosis
- Bacterial culture was tested for the three common bacterias associated with otitis media (Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis), which turned positive
- Inflammation of the pharynx was observed (Pharyngitis)
- Nasal swap subjected to microbial culturing indicated that the microorganisms tested were the three common bacteria associated with otitis media.
- Middle ear fluid signified rupture of the tympanic membrane
Plan
Orders
Prescription
Initial prescription to the patient did not change the condition. This signified development of resistance against amoxicillin antibiotics. An alternative medication like amoxicillin-clavulanate was prescribed. After 30 days of effective administration of amoxicillin, persistence of the condition indicated the patient developed resistance to medication. Resistance to antibiotic is a serious problem reported in previous literature (Lieberthal et al., 2013). Monitoring of patients for resistance development is essential in ensuring effective management of the condition. Pain relieving oral agents like paracetamol and ibuprofen was included in the prescription to help relieve pain and stabilize the patient. These drugs were prescribed for oral administration for the duration of one week. The dosages prescribed were 150mg/kg body weight for all drugs.
Diagnostic testing
Bacterial cultures were used in diagnosis of otitis media. This involved collection of the fluid and nasal swap. These were cultured on selective media that selected growth of the three specific microorganisms associated with otitis media. Targeted bacterias were Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis. These tested positive. Other diagnostic procedures involved observation of the pharynx for inflammation (Pharyngitis). Besides, tympanostomy tube was used to assess perforation of the tympanic membrane as a possible cause to the serous fluids (Lieberthal et al., 2013; Pettigrew et al., 2011).
Problem oriented education
A CPT CODES of 99402 was assigned to parents accompanying the patient and educated on factors that aggravate otitis media. These included personal care at home and refraining from social habits like smoking and drinking. Some parents buy drugs over the counter. Such habits are associated with development of resistance to antibiotics. Therefore, guardians and parents were advised to avoid using ‘over the counter’ medication. Besides, they were told to adhere to the prescription and report any observable changes along the duration of medication.
Health Promotion and Maintenance Needs
Good personal care to the patient improves their response to medication (Zhou et al., 2008). Acute otitis media requires good care at home or at health facility. This involves good hygiene of the environment to prevent external factors from gaining access to the ears. Besides, proliferation of causative agents associated with upper respiratory tract infections is common in dirty environment (Lieberthal et al., 2013). To ensure the patient is free from either Streptococcus pneumonia, Heamophylus influenza, or Moraxella catarrhael, hygiene of the environment is important (Lieberthal et al., 2013).
Referrals
The patient did not merit the need for specialized medical attention. Conditions that required referrals were listed in the patient medication book. Previously, the patient visited a general practitioner who prescribed antibiotics for 30 days. This medication was changed because development of resistance was suspected. The patient has since been given alternative medication for 7 days awaiting further outcomes. This forms the basis for referral for specialized attention if condition worsens.
Cultural Diversity
The patient does not merit a change of cultural value to improve the current condition. However, one value that needed consideration was the parent’s habit of smoking. Smoking is a risk factor that worsens the patient’s condition.
Patient/Family Education
The period for current medication has since ended. If the patient was still taking previous medication, we could have recommended discontinuity. The patient was not responding positively to antibiotics, suggesting the possibility of drug resistance (Lieberthal et al., 2013). The family has basic education on the patient’s condition. This could have aggravated the condition of the patient. The family was educated on risk factors associated with otitis media and how to manage them at home. An IC-9 CODES of V15.82 was assigned to the guardians. They were advised to avoid over the counter drugs and to follow the prescription appropriately.
Follow-Up Plans
The patient was booked for follow ups after two weeks interval. The follow up will address proper administration of prescribed medication and to ensure the parents take into account the training on well management to the patient.
References
Grijalva, C.G., Nuorti, J. P., & Griffin, M.R. (2009). Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA, 302(1), 758–766.
Lieberthal, A.S., Carroll, A.E., Chonmaitree, T., Ganiats, T.G., Hoberman, A., Jackson, M.A., …Tunkel, D.E. (2013). The Diagnosis and Management of Acute Otitis Media. Pediatrics, 131(3), 964–999.
Pettigrew, M.M., Gent, J.F., Pyles, B.R., Miller, A.L., Nokso-Koivisto, J. & Chonmaitree, T. (2011). Viral-Bacterial Interactions and Risk of Acute Otitis Media Complicating Upper Respiratory Tract Infection. Journal of Clinical Microbiology, 49(11), 3750–3755.
Zhou, F., Shefer, A., Kong, Y., & Nuorti, J. P. (2008). Trends in acute otitis media- related health care utilization by privately insured young children in the United States, 1997-2004. Pediatrics, 121(1), 253–260.