Assessing the Head, Eyes, Ears, Nose, and Throat

Case Study:Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.

 

 

·      Consider what history would be necessary to collect from the patient.

·      Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

·      Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

 

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditionsfor the patient’s differential diagnosis and justify why you selected each.

 

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