Head to Toe Assessment

Physical Examination

Sarah requires an ENT examination focused on the ear canal and eardrum. Therefore, a medical practitioner would need to perform the following physical exams. First, a physical examination of the ear canal and eardrum using an otoscope for signs of infection, redness, swelling, fluid buildup, discharge from the ear, or other abnormalities (Calatayud-Sáez et al., 2022). Second, tympanometry and pneumatic otoscopy is a physical diagnostic process for measuring middle ear fluid pressure to evaluate tympanic membrane mobility and the development of middle ear effusion. Additionally, touching or pulling on the ear to check for signs of pain or discomfort due to eardrum rupture.

Diagnosis

Based on the symptoms, the diagnosis for Sarah is acute otitis media (AOM), a widespread aural ailment in early childhood. AOM often occurs in young children after a viral upper respiratory illness (Ahmed et al., 2021). The disease is characterized by symptoms like earache, fever, and trouble hearing.

Treatment and Educational Plan

Sarah has AOM symptoms, and she is allergic to penicillin. Therefore, Sarah’s treatment strategy should include antibiotics like macrolides and cephalosporins. The dosage of the preferred cephalosporin, cefdinir, is 14 mg per kilogram per day. Antibiotics may be used with painkillers like ibuprofen to reduce the intensity of any pain or fever (Spoială et al., 2021). Ibuprofen and acetaminophen are accessible without a prescription. Sarah’s mother should be encouraged to avoid exposing her daughter to secondhand smoke and promote proper hygiene practices to reduce the chance of future infections.

Concerning the education plan, Sarah’s mother should be educated about the symptoms of AOM, the need to finish the complete dosage of antibiotics, the importance of check-ups, and the need to seek further medical treatment if the illness does not improve or if new symptoms appear. In addition, the parent should be educated on ways to keep children’s ears healthy and pain-free at home. Sarah’s mother should warm compress her ear and allow Sarah to sleep with her head raised to relieve the discomfort.