The case study that I have been assigned to involves a 57 year old man complaining of pulsating ear pain for 3 days. Based on the data obtained, Vital signs are stable with a slight temperature. The patient admits to pain, but once drainage resolved, the pain became less. Ear pain can have causes that are not due to underlying diseases. Some reasons that ear pain can occur is due to tight headwear, poorly fitting headphones, sleeping on a hard surface, ear piercings, grinding teeth, or with exudate and crusting. The patient denies loss/ability to hear.
During my assessment, the subjective data that I would obtain would be as followed; Do you have a history of allergies? With seasonal allergies it can cause ear pain. Did you use any over the counter meds for the symptoms? Have you been on an airplane in the past week or participated in any water sports? Ear pain 5/10 on a pain scale and admits to a headache. Objective symptoms include drainage from left ear with small amounts of blood. Temperature noted at 100.3 orally.
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I would consider a Middle ear infections (Otitis Media) because they often go away on their own within 2 or 3 days, even without any specific treatment. This middle ear infection occurs suddenly. It causes swelling and redness whereas, fluid and pus are trapped under the eardrum (Jarvis, 2016). A fever is sometimes noted. Typically this type of infection is seen in smokers or being around someone who smokes, have seasonal or year-round allergy symptoms, have a cold or other upper respiratory infection. The patient denies any past medical history. Fungal ear infection is an infection of the ear with a fungus. It normally involves the canal that runs from the ear hole to the eardrum.
The medical term for it is otomycosis. Fungal infection looks just like an infection from bacteria. Most fungal infection will only be suspected if your infection does not improve with antibiotic drops prescribed for a bacterial infection ( Rhoads, 2021). Fungal infection of the ear is more common in people living in tropical and subtropical countries. Some symptoms of otomycosis are pain, itching, inflammation, swelling, redness, discharge of fluid from the ears and hearing problems. A perforated eardrum may be caused by loud sounds, a foreign object in the ear, head trauma, a middle ear infection, or rapid pressure changes, such as from air travel. Symptoms may include sharp ear pain that subsides quickly, drainage, ringing in the ear, or hearing loss (Jarvis, 2016). This condition usually heals on its own within a few weeks. Antibiotics, an eardrum patch, or surgery may be necessary.
However, I would perform is medical history and do a physical exam, while looking at the outer ear and eardrum with an otoscope or an otomicroscope. A test called tympanometry will be performed to tell how well the middle ear is working. If needed the diagnostic test I will order is a CT scan of the face or refer to an ENT. The treatment of choice for these conditions will be antibiotic therapy for a few days or weeks depending on the severity of the infection. Acetaminophen for the fever and encourage oral hydration.
Jarvis, C. (2016). Physical Examination & Health Assessment (7th ed.). St. Louis, Missouri: Elsevier. ISBN: 9781455728107
Medical information and health advice you can trust. (2016). Retrieved November 04, 2020, from http://www.healthline.com/
Rhoads, J., & Wiggins Petersen, S. (2021). Advanced Health Assessment and Diagnostic Reasoning. Burlington, MA: Jones and Bartlett Learning. ISBN: 9781284105377
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