Patient Assessment, Diagnosis, and Management

Patient Assessment, Diagnosis, and Management


The ICD classification of Paddy’s condition will be H65.0 which is acute serous otitis media (“ICD-10 Version: 2016”, 2017). The disease is characterized by the redness and bulging of the tympanic membrane due to inflammation and accumulation of serous fluid. A patient also experiences stabbing pain in the ear which can be temporarily relieved by analgesics. The infection also causes fever due to inflammatory processes in addition to lymphadenopathy as a result of the increased immune function in the lymph nodes.

The management of Paddy’s condition should begin with adequate analgesia to achieve pain control since he still complains of pain in the ear. Antibiotics should be administered to eradicate the causative streptococcal bacteria. High dose amoxicillin is the antibiotic of choice for acute otitis media provided that sensitivity to penicillin has been ruled out. A re-examination should be done when symptoms persist after three days and better drugs such as amoxicillin/clavulanate (Lieberthal et al, 2013). Patient education involves cautioning against the use of nasal decongestants and nasal steroids since they do not hasten healing. Observation of vital signs should be done to detect any changes in condition and note improvement.


The ICD-10 classification of Tommy’s condition will be H60.3, other infective otitis externa specifically the swimmer’s ear (“ICD-10 Version:2016”, 2017). The infection starts with itching of the external ear followed by ear pain just like Tommy had complained. Pain is also reported with the palpation of the tragus and the traction of the pinna. The ear canal in swimmers ear is erythematous and edematous with debris due to the breakdown of skin and follicles. A patient also experiences the tenderness of the pre-auricular and post auricular lymph nodes as it is the case with Tommy.

Tommy’s condition requires active pain control since the pain was not relieved by acetaminophen. Intravenous analgesics may be given top Tommy to alleviate the pain. Antibiotics to eradicate the streptococcal infection such as amoxicillin should be administered to Tommy (Rosenfeld et al, 2014). The patient should be discouraged from swimming in the salty water, inserting fingers into the ears and also scrubbing the ears so much with a lot of water. Observation of vital signs should be done to monitor response to treatment and indicate the need for termination or change of therapy.


Mary’s classification according to ICD 10 will be J02.0 which is streptococcal pharyngitis (“ICD-10 Version: 2016”, 2017). Lab tests have already shown the presence of streptococcal infection. The oropharynx is erythematous with white exudates in streptococcal pharyngitis and is accompanied by the enlargement of the tonsillar lymph nodes. The cervical lymph nodes are also swollen and tender due to increased activity of the immune system.  The infection is also characterized by fatigue and chills due to the disease process. A patient experiences difficulty swallowing due to the inflammation and swelling of the oropharynx.

Mary’s condition may resolve on its own but treatment can be administered to alleviate the symptoms. However, Mary should be treated because the untreated illness of her daughter spread to her and the twins hence failure to address it may spread to other family members. The management of streptococcal pharyngitis involves the use of antipyretics to control fevers. Penicillin is the antibiotic of choice for the management of acute pharyngitis (Cots et al, 2015). Mary can, therefore, be given amoxicillin or any other penicillin if she is not allergic to penicillin. The patient should be encouraged to have some rest due to the fatigue which comes with the infection. Adherence to drug therapy should be encouraged not just for Mary but also Tommy and Paddy.


Cots, J. M., Alós, J. I., Bárcena, M., Boleda, X., Cañada, J. L., Gómez, N., …&Llor, C. (2015). Recommendations for management of acute pharyngitis in adults. ActaOtorrinolaringologica (English Edition)66(3), 159-170.

ICD-10 Version:2016. (2017). Retrieved 6 September 2017, from

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., …& Schwartz, R. H. (2013). The diagnosis and management of acute otitis media. Pediatrics131(3), e964-e999.

Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R., Roland, P. S., Simon, G. R., Kumar, K. A., … & Robertson, P. J. (2014). Clinical practice guideline: acute otitis externa. Otolaryngology—Head and Neck Surgery150(1_suppl), S1-S24.





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