Case Study For Patient Complaining Of Left Ear Discomfort
Case Study For Patient Complaining Of Left Ear Discomfort
Patient’s information
Patient’s initials: C.F
Age: 35 years
Gender: male
Subjective Data
Chief complaint: left ear discomfort.
History of Presenting Illness: C.F, 35 year old male presented with complains of left ear discomfort for one day. He reports that it was of sudden onset and associated with pain and pus-like discharge that is foul smelling. He also reports of on and off episodes of hotness of body.
Current medications
None
Allergies
No known food or drug allergies.
Past medical history
No history of chronic illnesses
Social history
He is single and lives alone. He denies history of cigarette smoking. He occasionally takes alcohol during social events.
Family history
He is the 3rd born in a family of 6. All siblings are alive and well. Both parents are alive. Mother is hypertensive whereas father is diabetic. Case Study For Patient Complaining Of Left Ear Discomfort
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Review of systems
General: positive history of hotness of body. He denies having chills, weight loss or weight gain.
HEENT: Eye: no history of excessive tearing, eye discharge, pain or loss of vision. Ears: he has a positive history of left ear discomfort and drainage of pus-like discharge. Nose: he has a positive history of nasal congestion and rhinorrhoea. Throat: he denies sore throat, painful or difficulty in swallowing.
Respiratory: no history of difficulty in breathing, cough and chest pain.
Cardiovascular: no history of dyspnoea, shortness of breath, orthopnoea and palpitations.
GIT: no history of abdominal distension, abdominal pain, acid reflux, nausea or vomiting.
GUT: no history of dysuria, increased urinary frequency and urgency.
Musculoskeletal: he denies back pain, joint stiffness and swelling.
Psychiatric: no history of anxiety or depression. Denies self-harm or suicidal ideations.
Allergies
He has a positive history of seasonal allergies.
Objective Data
Physical examination
Vital signs
Bp- 110/68mmHg, Pr- 64bpm, RBS- 4.8mmol/l, RR- 16bpm, BMI- 25kg/m2, Temp- 37.8and Spo2- 98% in room air.
General: C.F, 35 year old male is in a fair general condition. He is alert, oriented in time, place and person. He appears to be in overall good health.
Systemic examination
HEENT: Head: Normocephalic, no bruising or masses. Eyes: Pupils are bilaterally and equally reacting to light. No exophthalmos or enophthalmos. Ears: the pinna is clean bilaterally. However there is pain on movement of the left ear and the external auditory canal is occluded with pus-like, thick material and the tympanic membrane is erythematous. Nose/Mouth/Throat: Mucous membranes are pink and intact. The pharynx is normal.
Cardiovascular/Peripheral Vascular: normoactive precordium. Normal heart sounds S1, S2 with no added sounds.
Respiratory: no chest wall deformities. The chest is clear and there is equal and bilateral air entry.
Diagnostic tools
Full hemogram: check the WBC count for evidence of infection.
Assessment
Differential diagnosis
Otitis media (H66.9): a disease that results from infection of the middle ear that is mostly caused by bacteria or viruses. It mostly arises secondary to other illnesses such as cold, flu or allergies (Danishyar A;Ashurst JV, 2022). The risk factors include people with recurrent upper respiratory tract infection, seasonal allergies and children between 6 months to 2 years. The clinical presentation includes; ear pain/discomfort, discharge and fever.
Acute sinusitis (J01.9): inflammation of the lining of the sinuses caused mostly by viral infections and in some cases bacterial infection (Battisti et al., 2022). It typically presents with runny nose, fever and nasal congestion.
Cerumen impaction (H61.2): accumulation of excessive cerumen which occurs when the natural elimination mechanism is inadequate or disrupted according to Michaudet C;Malaty J, (2018). Patients’ presents with symptoms of ear discomfort, ear pain, hearing loss, tinnitus, itching and otitis externa. Case Study For Patient Complaining Of Left Ear Discomfort
Plan
- PO amoxyclav 1g 12 hourly for 5/7.
- PO Paracetamol 1g 8 hourly for 3/7.
- PO cetirizine 10mg (nocte) for 3/7
References
Battisti, A. S., Modi, P., & Pangia, J. (2022, August 8). Sinusitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470383/
Danishyar A;Ashurst JV. (2022, January 21). Acute Otitis Media. https://pubmed.ncbi.nlm.nih.gov/29262176/
Michaudet C;Malaty J. (2018). Cerumen Impaction: Diagnosis and Management. American Family Physician, 98(8). https://pubmed.ncbi.nlm.nih.gov/30277727/
Case Study For Patient Complaining Of Left Ear Discomfort