Question

1. Please refer to the 'Advanced Physical Assessment' text, specifically 'Bates' Guide to Physical Examination and History Taking,' for assistance in ensuring the correct wording in your documentation.

2. In the case presented, Ibrahim, a 10-year-old Saudi boy, is accompanied by his father (Dad) due to a complaint of right ear pain lasting for three days. He denies having experienced a headache, nausea, vomiting, diarrhea, abdominal pain, or any burning or pain elsewhere.

For this scenario, please provide guidance on how you would document the history and physical examination accurately, taking into account the provided case information.

Answer 1

When documenting the history and physical examination accurately for a 10-year-old boy with right ear pain, include relevant details and thoroughly examine the ears, nose, and throat.

Step-by-step explanation:

When documenting the history and physical examination accurately for Ibrahim, the 10-year-old boy with right ear pain, it is important to include relevant details. In the history, you should note the duration of the pain, any associated symptoms like headache or nausea, and any other medical conditions.

Regarding the physical examination, you should assess the ears, nose, and throat, checking for signs of infection or inflammation. Specifically, you should examine the external ear, tympanic membrane, and use tools like otoscope for a thorough evaluation. Make sure to document your findings accurately and clearly.