Otitis media

Order Description

Create a scenario using the attched table and work up a final diagnosis for a pediatric patient seen in the clinic. Your final diagnosis should be otitis media

Name:   Pt. Encounter Number:

Date: Age: Sex:

SUBJECTIVE

CC:  

Reason given by the patient for seeking medical care ìin quotesî

 

HPI:  

Describe the course of the patientís illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.

 

Medications: (List with reason for med )

 

PMH

Allergies:  

 

Medication Intolerances:

 

Chronic Illnesses/Major traumas

 

Hospitalizations/Surgeries

 

ìHave you ever been told that you have  diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?î 

 

Family History

Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?

 

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status

 

Assessment specific to disease system- 

Lab Tests

Urinalysisópending

Urine cultureópending

Wet prepópending

 

Special Tests

 

 Diagnosis

o Include at least three differential diagnosis

o Final diagnosis

? Evidence for final diagnosis should be documented in your Subjective and Objective exams.

PLAN including education

o Plan:  

? Further testing

? Medication

? Education

? Nonmedication treatments

? Follow-up

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