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 “in quotes”

HPI:
Describe the course of the patient’s 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

“Have 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?”

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
Urinalysis—pending
Urine culture—pending
Wet prep—pending

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