Physical Examination and Laboratory Tests general: Patient lying supine; WDWN yo
ID: 243803 • Letter: P
Question
Physical Examination and Laboratory Tests
general:
Patient lying supine; WDWN young female; Now crying with intermittent screaming
Vital signs:
BP= 105/65; RR= 35; WT= 20 lbs; HR= 145; T= 102 degrees F with ibuprofen; HT= 30 in
Head, eyes, ears, nose, and throat
pupils equal at 3 mm, round, responsive to light and accommodation; (+) tears; both TMs bulging with no mobility; left TM is yellow and opaque and there appears to be some purulent fluid behind it; right TM is erythematous; no otorrhea present; nares patent with no discharge; throat shows significant erythema
neck/lymph nodes
neck supple with no apparent pain or stiffness with movement; no lymphadenopathy
chest
clear to auscultation bilaterally without crackles or wheezes; chest wall rise is symmetric
cardiac
regular rate and rhythm with no murmurs, rubs, or gallops
abdomen
soft, non-tender, and non-distended; (+) bowl sounds; (-) hepatosplenomegaly and masses
genitalia
normal-appearing external genitalia
extremities
20 digits; no cyanosis, clubbing, or edema; brachial pulses palpable; capliiary refill WNL; moves all extremities well; skin is warm and pink with no rashes or lesions
neurologic
responsive to stimulation; depp tendon reflexes 2+ throughout; cranial nerves intact; hearing appears intact; motor exam shows normal muscle tone and bulk; facial strength appears symmetric and normal
lab blood test results
WBC= 12,100/mm^3; lymphs= 21%; Eos= 1%; Plt= 270,000/mm^3; Neutros= 75%; Monos= 3%; RBC= 5.0 million/mm^3; ESR= 18 mm/hr
Questions: What subjective clinical information supports a diagnosis or acute otitis media? What objective clinical data support a diagnosis of acute otitis media?
Explanation / Answer
TMs bulging with no mobility; left TM is yellow and opaque and there appears to be some purulent fluid behind it; right TM is erythematous supports the diagnosis of acute otitis media.
Objective clinical data which supports are:
Febrile as she has 102 degree farenheit
TM effusion and bulging
Purulent fluid behind TM
Increased WBC