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In the history of presenting illness, establishing the time of onset of the condition will be essential. This will enable ruling out of the condition to either acute or chronic. Finding out the character of pain that the child has will be done too. The score of pain will be graded by the discomfort that the child will be exhibiting. The site with pain will also have to be identified. This will be achieved by asking the patient to point the area of pain or by observing where the child will be holding hands when feeling the pain. Pain will then be classified as either referred or localized to a specific site. It will be necessary to identify the conditions that exacerbate the patient’s disease. This will be achieved by asking them what makes the pain worse or even asking the parents what made the pain worse. This will include finding out if the pain varied the positioning in the body. The relieving factors will also be identified (Swash and Glynn, 2007).
In the review of systems, other systems apart from the specific system of inquiry are examined. This will involve examining all other systems apart from the head, neck, ear, and throat. The other systems will include the respiratory, cardiovascular, genitourinary, gastrointestinal, and respiratory systems. The aim of reviewing of these systems is to establish if there is another pathology that could be precipitated by the condition such as upper respiratory infections (Pittler, Altunç & Ernst, 2007).
On inspection of the external ear, there will be a need to check on the symmetry of the ears, presence of deformities and scars, involuntary movements and edema. Inflammation will be present. Then will be done the examination of the ear canal and the eardrum. This will involve the use of the otoscope. The otoscope will enable the visualization of any discharge, foreign bodies, dull appearance or inflammation. In this case, the eardrum is expected to be red and bulging. There will be loss of the outline of the drum and the landmarks. The landmarks (umbo, light reflex and the handle together with the short process of the malleaus) are obscured in this patient. On palpation, the patient will elicit tenderness on the ear that is affected. The superficial lymph nodes are likely to be enflamed and will elicit tenderness on touching. The hearing of the child will also have to be ascertained. This will be achieved by using the Rinne Webster tests or the use of crude testing where words are whispered into the child’s ear (Swash & Glynn, 2007).
Other assessments will include examination of the eye, throat, teeth, and gums. This will involve inspection for vision, asymmetry, deformities, lesions, or ptosis. The eyes will also be inspected for excessive tears or discharge. Finally, the extra ocular movement and ocular alignment will have to be determined. Examination of the nose will involve inspecting the nose for any forms of swelling, bleeding, abnormal lesions, and secretions. These will enable the ruling out of upper respiratory tract infections. The throat and mouth are examined together. Examination of the mouth will begin with visual inspection of the mouth. This will include the inspection of the color of the lips, texture and any anatomical defects or ulcerations. Visualization of the tonsils will also be done. Teeth will be inspected for breakages. At the same time, gums will be inspected for inflammation, bleeding, and infection. Examination of the neck is achieved by checking for symmetry of the thyroid gland and presence of lymphadenopathy (Swash & Glynn, 2007).
The diagnosis for the above condition is Acute Otitis media. The diagnosis is based on the clinical presentation of the patient. The patient is reported to be irritable, pulling ears and had not been herself the whole day. On examination, the right tympanic membrane was red. The differential diagnosis for this patient would be Serous Otitis media, Chronic Otitis Media, Otitis Externa, Mastoiditis (Bhetwal & McConaghy, 2007).
Management of the Condition:
The used management forms will be the definitive and supportive management. Supportive management would entail giving of analgesics such as acetaminophen or ibuprofen for the pain that the child has. Definitive management will involve the use of antibiotics. The first line therapy would entail the use of amoxicillin. If the patient has type one resistance to penicillin, he can be given azithromycin 10mg/kgBwt/day for the first day then followed by 5mg/kgBwt/day for the next 4 days. On the other hand, if the patient has non-type one reaction to penicillin he can be given cefuroxime 30mg/kgBwt/day divided in two doses for seven to ten days. Surgery will be done in a case if the ear infection keeps recurring after taking the antibiotics (Bhetwal & McConaghy, 2007).