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

CHIEF COMPLAIN: Ear ache for the past 2 days. 

History of Present Illness:  The patient is an eleven year old grandson with an ear infection.   The patient complains of mild ear ache for the past two weeks. The pain has been worse mostly when he sleeps making it harder for him to hear,  the initial assessment shows James with a prominent tan which is possibly caused by him being at the pool. 

Medication: Debrox, OTC ibuprofen, Depo-provera 150mg/ml injection. 

Immunizations: Childhood vaccine including Gardasil. 

Allergies:  NKDA

Family History:  All family members are alive. No history of ear problems/ 

Health Maintenance:  The first examination done this day. 

HEENT:  No history of ear injury, however reports trouble hearing, vertigo, denies tinnitus, states that his hears hurt and they feel full.  Nose: patient reports occasional cold. Throat: Last dental visit was 9 months ago, patient denies any pain and bleeding. Patient able to swallow and chew with little difficulty.

Neck: Denies changes and pain.

Cardiovascular: Shortness of breath, no cough and wheezing (Gotthelf, 2005). 

Cardiovascular: No history of heart disease or palpitations.
Gastrointestinal: Denies heart burn. Appetite is good Bowel movement every day of normal consistency and color, and without bleeding. Denies any pain, nausea, or vomiting. 

Urinary: denies any burning, or pain. 

Endocrine: temperature intolerances, denies thyroid problems, Sweating is average

 

Vital Signs:  Blood Pressure 102/64, heart rate 80, respirations 16, temperature 97.7 orally, Weight 132 Lbs, Ht 60.5 inches, BMI 25.35

PHYSICAL EXAM:

General: Patient is 11 years old, appears uncomfortable, of average height.  Normal movement and posture. Responds to questions quickly (Ocak, Duman, & Tekin, 2019). 

Skin:  Normal color, but pink on the infected ear. 

Neck: trachea is midline, Neck midline without pulsations, thyroid is barley palpable and soft. 

Lymph Nodes: no lymphadenopathy. 

Thorax and Lungs: Thorax is with good excursion. Breath sound are vesicular bilaterally. 

LAB/DIAGNOSTIC TESTS/EKG: 

Due to the visualization of the cerumen in the ear canal no testing is indicated related to the symptoms. 

IMPRESSION/PLAN:

380.4--Cerumen impaction 

 

Differential Diagnosis

• External Otitis- This is typically presented with foul smelling otorrhea that could not be present in the patient. Also the pain is reduced after ear canal and irrigation was clear and slightly swollen or red. 

• Foreign body in ear canal- this is often unilateral and the foreign body could be viewed during examination that was not discovered or noted. 

 

References

Gotthelf, L. N. (2005). Primary causes of ear disease. Small Animal Ear Diseases, 111-125. doi:10.1016/b0-72-160137-5/50008-8

Ocak, E., Duman, D., & Tekin, M. (2019). Genetic causes of inner ear anomalies: A review from the Turkish study group for inner ear anomalies. Balkan Medical Journal, 36(4), 206-211. doi:10.4274/balkanmedj.galenos.2019.2019.4.66