Mild Earache Complain

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

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.

To Prepare

· By Day 1 of this week, you will be assigned to a specific case study

CASE STUDY 1: 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.

· 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.

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 five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

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

Episodic/Focused SOAP Note

Patient Information:

• Name: James
• Age: 11
• Gender: Male
• Chief Complaint: Mild earache for the past 2 days

Subjective:

• Martha brings her grandson, James, to the clinic for a check-up on his right ear.
• James has complained of a mild earache for the past 2 days.
• Martha notes that James feels warm but did not confirm with a thermometer.
• James mentions that the pain worsens when falling asleep and he experiences difficulty hearing.
• James has spent a lot of time in the pool over the summer, resulting in a prominent tan.

Objective:

• Vital Signs:
  • Temperature: Not measured
  • Pulse: [within normal range]
  • Respiratory Rate: [within normal range]
  • Blood Pressure: [within normal range]
• Inspection:
  • Right ear: Mild erythema, possible fluid behind the tympanic membrane
  • No visible discharge or signs of trauma
• Otoscopic Examination:
  • Right ear: Tympanic membrane appears inflamed, slightly bulging, limited mobility noted
• Audiometry: Recommended to assess hearing loss and severity
• Skin examination: Note any signs of swimmer’s ear or dermatological conditions related to prolonged exposure to pool water.

Assessment:

1. Otitis media: Inflammation of the middle ear, possibly due to water exposure during swimming.
2. Swimmer’s ear (Otitis externa): Inflammation of the outer ear canal, also likely due to prolonged swimming.
3. Tympanic membrane perforation: Possible complication if the inflammation is severe.
4. Cerumen impaction: Considered due to ear discomfort, especially if exacerbated by water exposure.
5. Eustachian tube dysfunction: Potential cause of ear pain and difficulty hearing, especially considering the recent swimming activities.

Plan:

1. Prescribe analgesics for pain relief.
2. Recommend avoiding water exposure to the affected ear.
3. Prescribe topical antibiotics if signs of infection are present.
4. Refer for audiology evaluation for audiometry testing.
5. Provide education on ear hygiene and prevention strategies for future swimming activities.

Evidence-based Diagnostic Tests:

• Audiometry: To assess hearing loss and determine the severity.
• Otoscopy: To visualize the ear canal and tympanic membrane for signs of inflammation or infection.
• Culture and sensitivity testing: If infection is suspected, to identify the causative organism and guide antibiotic therapy.

Differential Diagnosis:

1. Otitis media: Common in children, especially after swimming, presenting with ear pain and reduced hearing.
2. Swimmer’s ear (Otitis externa): Inflammation of the outer ear canal due to water exposure.
3. Tympanic membrane perforation: May occur secondary to infection or trauma.
4. Cerumen impaction: Build-up of earwax leading to discomfort and reduced hearing.
5. Eustachian tube dysfunction: Dysfunction of the tube responsible for equalizing pressure in the middle ear, leading to ear pain and hearing difficulties.

These differential diagnoses are chosen based on James’ symptoms and history, considering common conditions associated with ear pain and swimming activities. Further diagnostic tests and clinical evaluation will help confirm the specific diagnosis.