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Case Study Assignment-Assessing the Head, Eyes, Ears, Nose, and Throat

Case Study Assignment-Assessing the Head, Eyes, Ears, Nose, and Throat

Patient Information:

  1. 11 years old, Male

CC (chief complaint); Right ear mild earache for 2 days, pain becomes worse while asleep that makes it harder for him to hear.

Feels warm(Grandmother to the patient)

HPI: 11-year-old male J. presented to the clinic accompanied by his grandmother, complaining of mild earache in his right ear for the past two days. The patient feels pain that worsens while asleep, which makes it harder for him to hear. The grandmother claims that the patient feels warm, though she did not confirm it using a clinical thermometer. The patient has been spending a lot of his summer in the pool.

Current Medications: The patient did not mention any form of medications he is taking currently.

Allergies: He has no known drug allergies.

PMHx: The patient has no history of chronic illnesses, surgeries, blood transfusion or admission to the hospital.

Soc Hx: No history of current use of alcohol or drugs. The patient stays with his grandmother and spends his summer mostly in the pool.

Fam Hx: There is no history of contagious or chronic illnesses like diabetes and cancer running in the family.

ROS:

GENERAL:  Denies weight loss, chills, weakness or fatigue. The grandmother to the patient reports that the patient feels warm.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: He reports no sneezing, congestion, runny nose or sore throat. The patient complains of mild earache in his right ear, which worsens when he is asleep and makes it harder for him to hear.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No complaints of pain during urination

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies a history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

Physical exam: On basic assessment, a prominent tan was noticed on the patient. Measuring the temperature of the patient to confirm his grandmother’s claim that the patient was feeling warm.

Diagnostic results: Pneumatic otoscope to confirm and check if there is fluid buildup behind the eardrum, visual inspection of the tympanic membrane and external auditory canal with an otoscope.

Tympanocentesis: Under local or general anesthesia, a needle is used to extract fluid or pus from the middle ear. This fluid can then be cultivated to see if there are any bacteria present. The lab can identify which medications are appropriate for treatment after the germs have been cultivated. However, germs are not always present in the fluid.

Tympanometry involves inserting a soft plug into the ear canal. It is capable of detecting eardrum movement.

A complete blood count and erythrocyte sedimentation rate (ESR) studies to check the infection(Meadows‐Oliver, M. 2020).

Dental radiography and CT scanning to rule out problems referred to pain from dental disease, neck, sinuses, head, or temporal region.

Differential Diagnosis;

Otitis externa is inflammation of the external auditory canal and it is commonly referred to as swimmers ear. Swimming and other water activities, as well as trauma from excessive washing, can induce skin maceration and a breakdown of the cerumen–skin barrier, leading to inflammation, oedema, and pruritus, which can lead to scratching and further damage(Rosenfeld.,,2014). The earwax in the ear is hygroscopic, which means it can absorb or adsorb water, and it generates an acidic environment in the ear that prevents bacterial and fungal growth. The pH of the ears rises as a result of reduced cerumen synthesis and impaired epithelial migration, creating a more hospitable environment for infection. The patient spends most of the time in the pool and hence can make this a possible diagnosis.

Acute otitis media, inflammation of the middle ear, and is characterized by irritability, and children can demonstrate fever, and if it proceeds to effusion, hearing loss becomes significant (Leung, 2017). The feeling of warmth of the patient can depict fever which can confirm a diagnosis.

Otitis media with effusion (OME), is a condition presenting with conductive hearing loss. The patient presents with hearing loss or difficulty in hearing while asleep, which can confirm OME as a diagnosis.

Eustachian tube dysfunction, otoscopic evidence of tympanic membrane retraction and/or tympanogram indicating negative middle ear pressure are signs and symptoms of eustachian tube dysfunction, which is diagnosed using otoscopic evidence of tympanic membrane retraction and/or tympanogram indicating negative middle ear pressure(Smith.,,2018). This can be a possible diagnosis due to hearing loss while asleep.

Mastoiditis, an infection in the air cells of the skull behind the ear. Physical examination and observations of soreness, erythema, edema, and warmth in the mastoid region led to this diagnosis. The patient’s grandmother says the patient is warm, which could result from mastoid region warmth due to mastoiditis.

 

 

References

Meadows‐Oliver, M. (2020). Earache. The Family Nurse Practitioner: Clinical Case Studies, 53-56. https://doi.org/10.1002/9781119603238.ch3.1

Leung, A. K., & Wong, A. H. (2017). Acute otitis media in children. Recent patents on inflammation & allergy drug discovery11(1), 32-40. https://doi.org/10.2174/1874609810666170712145332

Smith, M. E., Takwoingi, Y., Deeks, J., Alper, C., Bance, M. L., Bhutta, M. F., … & Tysome, J. R. (2018). Eustachian tube dysfunction: a diagnostic accuracy study and proposed diagnostic pathway. PloS one13(11), e0206946. https://doi.org/10.1371/journal.pone.0206946

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. https://doi.org/10.1177%2F0194599813517083

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Question 


Case Study Assignment-Assessing the Head, Eyes, Ears, Nose, and Throat

CASE STUDY 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 2 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.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

Case Study Assignment-Assessing the Head, Eyes, Ears, Nose, and Throat

Case Study Assignment-Assessing the Head, Eyes, Ears, Nose, and Throat

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

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