Case Study For HEENT Discussion Paper

Case Study For HEENT Discussion Paper

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Physical Assessment

Case Study Template

Name: ________________________________________

Week of Class (1-8): ______

Body System focus area (i.e., cardiovascular): _____The Auditory System ________________________

Case Study: Case 1: A 21-year-old male athlete complains of irritation and fullness in his right ear. He has trained for 6 hours daily, including swimming, running, cycling, and weightlifting. He is concerned that the fullness in his ear and the irritation could require him to limit his training. He denies any recent upper respiratory infections, nausea, vomiting, or dizziness.

Questions (if data is unavailable, indicate “unavailable” ):

1. What is the client’s chief complaint?

“I have been experiencing irritation and fullness in my right ear.”

2. What questions would you ask the client?

• Have you ever experienced such symptoms before? If so, how long and which medication were you given?
• Do you have hearing loss?
• Have you ever undergone tympanoplasty with mastoidectomy? If so, what were the results?
• Has any of your immediate family members experienced Otitis Externa?
• Does any intervention, such as taking exercise breaks, make the situation better? Case Study For HEENT Discussion Paper
  

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3. What physical examinations would you include?

4. What are pertinent positive physical assessment findings?

The patient’s pertinent positive, derived from the subjective and objective assessments, is that the patient presents signs and symptoms of Otitis externa. According to Wiegand et al. (2019), otitis externa’s main clinical features include progressive ear pain accompanied by a purulent discharge, fullness, and itchiness. The main risk factors include frequent water contact and engagement with humid environments. Case Study For HEENT Discussion Paper

5. What are the pertinent negative physical assessment findings?

Despite the patient presenting otitis externa symptoms like irritation and ear fullness, the conditions may also be present in other clinical presentations due to ear fullness and irritation.

What are at least three differential diagnoses (use Up-to-Date App if needed)?

• Ear canal carcinoma
• Ear canal trauma
• Otitis media with a perforation

6. What is your primary diagnosis?

The primary diagnosis is otitis externa which involves external auditory canal inflammation, which may be either chronic or acute. The reason for such an assertion is that the patient is a swimmer, an otitis externa risk factor.

7. What is your treatment plan?

• Diagnostic procedure

The main diagnostic procedures the patient will be exposed to include hearing and otoscopy procedures that will help provide more insight into the patient’s condition (Jin et al., 2022)Case Study For HEENT Discussion Paper. Such procedures will be effective in assessing ear wax and discharge.

• Labs

The main labs that will be involved include Rinne and Webbers tests. According to Chiong et al. (2020), Webber’s test is essential to assess the sound quality of the patient in both ears. On the other hand, Chiong et al. (2020) indicate that the Rinne test helps assess the air conduction in the patient’s ears.

• Client Education

The patient must be enlightened on the need to refrain from swimming until the healthcare professionals maintain the current condition. Also, patient education will need to incorporate the training and educating the patient on the signs and symptoms of otitis externa, its risk factors, the treatment procedures, and the need for follow-up to increase the patient’s chances of collaborating with the healthcare professionals. Consequently, the patient must acknowledge the need to use plugs when swimming to avoid water entering his ears.

• Pharmacotherapy

According to Wiegand et al. (2019), otitis externa is mainly treated using topical antibiotics like hydrocortisone, neomycin, and polymyxin. Other treatments include the use of Ciprofloxacin and Ofloxacin.

• Health Promotion

The main health promotion will emphasize the patient application of the pharmacotherapy interventions. In that case, the patient will be made to acknowledge that hydrocortisone needs to be administered to the right ear using three to four drops four times daily (Wiegand et al., 2019). However, if the patient will be administered Ofloxacin, the patient needs to apply five drops twice daily, while Ciprofloxacin with hydrocortisone needs to involve three drops twice a day on the affected ear. Case Study For HEENT Discussion Paper

• Follow Up

After resolving the otitis externa, the patient must collaborate with the primary care provider for a follow-up for approximately six weeks to help assess the otitis externa’s persistence.

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References

Chiong, C. M., Acuin, J. M., Patrick John Labra, & Chan, A. L. (2020). Ear, Nose, and Throat Disorders. 105–113. https://doi.org/10.1016/b978-0-323-55512-8.00012-0

Jin, Z., Gao, Y., Guo, X., Wen, J., Li, Z., & Jin, Z. (2022). EarHealth: an earphone-based acoustic otoscope for detection of multiple ear diseases in daily life. Association for Computing Machinery. https://doi.org/10.1145/3498361.3538935

Wiegand, S., Berner, R., Schneider, A., Lundershausen, E., & Dietz, A. (2019). Otitis externa—investigation and evidence-based treatment. Deutsches Aerzteblatt Online, 116(13). https://doi.org/10.3238/arztebl.2019.0224

Week 2 Case Study: HEENT

Instructions:

• Use the Case Study Template to complete. Download Use the Case Study Template to complete.
• Be sure to include at least one reference.
• Include in-text citations as needed. Case Study For HEENT Discussion Paper

Select one case to discuss.  

• Case 1: A 21-year-old male athlete presents with complaints of irritation and fullness in his right ear. He has been training for 6 hours a day, including swimming, running, cycling, and weightlifting. He is concerned that the fullness in his ear and the irritation could require him to limit his training. He denies any recent upper respiratory infections, nausea, vomiting, or dizziness.
• Case 2: A 19-year-old male returns from a recent trip with his basketball team complaining of a sudden onset of progressive severe throat pain, fever, headache, muscle pains, and malaise x 1 day. He denies any coughing, sneezing, nausea, vomiting, or nasal discharge. Childhood immunizations completed: tetanus booster given two years ago. He shares that a few of his teammates also became sick.
• Case 3: A 26-year-old female complains of body aches and low-grade fever x 4 days with a non-productive cough. Her mother has had similar symptoms x 2 days. She recently attended a party; however, all of the guests were fully vaccinated against the COVID-19 virus. Her last menstrual period was regular 3 weeks ago. Case Study For HEENT Discussion Paper