Sara H Perry-Nelson

Review of Case study # 3

NURS 6512

Case 3: Focused Ear Exam

Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He

has complained to her about a mild earache for the past two days. His grandmother believes that

he feels warm but did not verify this with a thermometer. James states that the pain was worse

while he was falling asleep and that it was harder for him to hear. When you begin basic

assessments, you notice that James has a prominent tan. When you ask him how he's been

spending his summer, James responds that he's been spending a lot of time in the pool.

Patient Information:

JM, age 11, Male, caucasion

S.

CC: “My ear has been kind of hurting for two days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section

is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the

patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with

age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each

principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the

HPI might look like the following example:

Location: Right ear

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Onset: 2 days ago

Character: Achy

Associated signs and symptoms: pain when laying on right side is sore

Timing: Bothers all the time

Exacerbating/ relieving factors: Lying on right side or going to sleep makes it worse,

Ibuprofen helps

Severity: 4/10 pain scale

Current Medications:

OTC Ibuprofen 200 mg, one tablet as needed every eight hours pain

Allergies: None

PMHx: Immunizations up to date, including last tetanus and flu shot November 2017. No

surgeries, no previous hospitalizations other than birth (uneventful, no complications).

Soc Hx: Lives with both parents, and one sister. Grandmother cares for when parents are

working. Enjoys swimming and playing outdoors. No exposure to secondhand smoke,

grandmother denies use of alcohol for and around child. Always wears seat belt, does not require

booster seat any longer, but continues to sit in back seat only. They have working smoke

detectors and carbon monoxide detectors in the house. Lives in quiet suburban neighborhood, a

few blocks from grandmother. NO text/cell phone use while driving. Family very involved in

local church and grandmother is secondary caretaker during parent’s work hours.

Fam Hx: grandfather passed away 2015 at age 67 from MI

ROS:

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