Ear Examination

Ear Examination

EAR EXAMINATION 5

EarExamination

SUBJECTIVEDATA

ChiefComplaint: Earache for two days

Asthe doctor, first I would follow the general health history forJames. is a crucial aspect that needs accurate andadequate information regarding the health history of the patient. Fewclaims that will help the doctor analyse an earache include a mildearache, pain during sleep, and his history of spending the summerperiod in cold.

Historyof present illness

Accordingto Jamesdescription’s history about his health, most probably hemight be experiencing ear infection. At his age, ear infectionincludes ear aching and difficultyin hearing. According to Jamescondition, he had a problem with hearing when he tries to sleep. Someof the symptoms that doctor need to check on include fever, pullingon the ears, irritability aspect of the ear, lacking appetite, anddiarrhoea (Holborow, 2006). Checking through the eardrum, it ispossible to locate the infection, this is through the tympanicmembrane.

Whichof the ears is affected?

Doesthe patient has associated sinus congestion?

Hasthe ear worsened suddenly or gradually?

Anydifficulty with hearing CALRITUY?

Thehigh-frequency hearing controls the clarity for conversation.

Finally,is there family history associated with ear problems?

Medications:Tylenol and Ibuprophen

Allergic:N/A

PastMedical History: Sinus infections

PastSurgical History: N/A

PersonalHistory: N/A

ImmunizationHistory: Flu

SignificantFamily History: N/A

Lifestyle:love swimming

Reviewof Systems:

Musculoskeletal:being tired

Psychiatric:difficulty with sleeping

Neurological:difficult with hearing at night

PhysicalExamination:

Temperature:it was above the normal standard.

Musculoskeletal:malaise

Neurological:tremors

Skin:warm and with tan

Treatment:

Anyinfection affecting the ear can be treated with antibiotics,painkillers and medicine to reduce fever, and observation. Painmanagement should be applied to James condition. Pain relievingmedicine includes ibuprofen and eardrops among others (Mawson, 2001).Some of the questions that are likely to be asked regarding thehistory of the era include:

Accordingto James case, he should include how he spent his summer in cold.Staying in the cold for a period leads to mucus stacking in themiddle ear space for a period (Saunders, 1999).

Therefore,the results will determine the kind of diagnosis the patient willreceive from the hospital. The doctor will conduct some tests to findout the kind of problem the ear is suffering, for example, it mightbe conducive, sensor neural or both (Hall, 205). The doctor will thentreat the difficulty. Additionally, referral to a hearing aid clinicis appropriate.

Assessment

Swimmersear: Have pain, itchiness, and sometimes unable to hear clear. Theear has red canal

TreatmentPlan

Applicationof polymyxin B sulphate. Alternatively, tobramycin dexamethasoneapplication.

References

HallJW, Grose JH, Pillsbury HC. (2005). Long-term effects of chronicotitis media on binaural hearing in children. Arch Otolaryngol HeadNeck Surg., 1995, 121 (8): 847-852.

HolborowC, McPherson B. (2006). Simple treatment for the infected ear.Tropical Doctor, 16: 31-32.

MawsonS, Ludman H. (2001). Disease of the Ear. A Textbook of Otology. 4thed. London, Edward Arnold Publication.

SaundersWH. (1999) Pre-treatment of chronic suppurative bone disease beforedefinitive surgery. Trans Am Acad Opthalmol Otolaryngol. 130-133.