A Focused Ear Exam
Review of Case Study 3: A Focused Ear Exam
Instructions:
In this Discussion, 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.
Note: By Day 1 of this week, your instructor will have assigned you to one of the following case studies to review for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Case 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 two 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.
To prepare:
With regard to the case study you were assigned:
•Review this week’s Learning Resources and consider the insights they provide.
•Consider what history would be necessary to collect from the patient.
•Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
•Identify at least 10 possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Week 5 Discussion”) with “Review of Case Study ___,” identifying the number of the case study you were assigned.
By Day 3
Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each
Solution
Review of Case Study 3: A Focused Ear Exam
Patient Initials: ____James Age: _11 years Gender: ______Male_
SUBJECTIVE DATA:
Chief Complaint (CC): James has experienced earache and temporary hearing loss for the past two days.
History of Present Illness (HPI):
Martha (his grandmother) reports that James has experienced constant mild pain in his right ear for two days. Further, James says that the ache was worse during the night and made it difficult for him to hear. Additionally, the grandmother states that James feels warmer than usual. The patient has experienced the problem for two days without medication. In addition, James does not have a history of earache. There is a need to outline the cause of the pain for effective planning and treatment. James requires an ear exam to determine the cause and possible treatment or ache management procedure.
Interests:
Inquiry into James’ interests and previous activities shows that he spent the summer swimming.
Review of Systems:
Examination shows that James has a prominent tan, but does not show any other complications or health concerns.
OBJECTIVE DATA:
The physical examination of James reveals a prominent tan by applying the pneumatic otoscope (Ball, Dains, Flynn, Solomon, & Stewart, 2014). From the knowledge that James’ spent a lot of time in swimming pool, the examination uses the otoscope to look in and determine whether there is liquid behind the eardrum. Additionally, the application of tympanometry determines the movement of the eardrum and the determination of what other procedures or medications are necessary for James to fully recover. The measurement of James’ temperature shows higher temperature that normal (at 40oC).
ASSESSMENT:
The earache James experiences is caused by infection. The infection results from accumulation of water behind the eardrum from swimming.
- Ear infection – Prominent tan due to water accumulation behind the eardrum (a lot of pain, temporary hearing loss mainly when sleeping, and high temperatures)
- Differential Diagnoses:
- Glue ear – caused by fluid accumulation in the ear drum. Patient experiences temporary hearing loss. However, the condition is painless (Dains, Baumann, & Scheibel, 2016).
- Earwax – Patients experience pain and temporary hearing loss, but does not characterize increase in body temperature or the development of a tan as is the case of James.
- Ear barotrauma – another possible diagnosis is ear barotraumas, which occurs from exposure of the ears to high pressure. The condition causes pain and temporary loss of hearing. However, James experiences pain in one ear. Further, he does not show any of the other symptoms of barotrauma such as dizziness or stuffed ears (Dains,Baumann, & Scheibel, 2016).
Previous Medication: He patient’s health history does not show
previous cases of infection, and therefore, no prior medications concerning or
related to the infection.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s Guide to Physical Examination (8th Edition ed.). London: Elsevier Health Sciences.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.