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Management of middle ear disease
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APA format in a SOAP Note format. 1 page long with questions as to which diagnosis would be accurate and why. I have included the references I need 3 peer review articles to be included Patient Information: Initials : JS Age : 11 Sex : M Race : Caucasian SJ CC: Patient complaining of a mild right earache for the last two days and trouble hearing from that ear. HPI : James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear. The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer. Current Medications : 1. Ibuprofen 600mg PRN for earache pain Allergies: NKA PMHx : Up to date on all immunizations. No significant PMH. Soc Hx : Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer. Fam Hx : Maternal grandmother died of a stroke at the age of 70. No other significant family history. ROS : GENERAL: No fever, fatigue or chills. No weight loss. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears: Patient reporting pain in right ear and hearing loss. Nose, Throat: No sneezing, congestion, runny nose or sore throat. SKIN: No rashes or itching. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. LYMPHATICS: No enlarged nodes. No history of splenectomy. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing. HEENT: PEERLA. Ears: Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact. Nose : Nose is patent without any rhinorrhea. Throat: Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012). SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good. RESPIRATORY: LS CTA bilaterally, no sternal retractions noted. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present. NEUROLOGICAL: Cranial ...
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Dix-Hallpike test
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Epley Manouvre
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Acute otitis media
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Perforation
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Cholesteatoma
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Retraction
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Case 1
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Case 2
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Case 3
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Case 4
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Case 9
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Case 10
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