Focused Ear Examination Soap Note Sample

Focused Ear Examination

Patient Information:

AL, 11, M, Caucasian male

CC: Ear pain

HPI: 11 years old Caucasian boy presents to clinic with chief complain of ear pain in right ear. Patient started complaining about pain to his grandmother two days ago after returning from the pool. He describes pain in the ear as pressure, that gets worst when he is falling asleep. This ear arch makes it harder to hear tsr. Patient rates his pain as 5/10 using the pediatric pain scale

Current Medications: none

Allergies: peanuts

PMHx: none

Soc Hx: patient is taking swim lessons. Lives in a two-bedroom home with grandparents who are smokers and two younger siblings. Patient uses sit belt all the time. His biological parents are both incarcerated for distribution of illegal drugs.

Family Hx: History of alcohol and drug abuse by the mother and father. HTN history from the father. Both maternal grandparents have HTN, maternal grandmother has COPD, not much is known about paternal grandparents. Two younger siblings are healthy.

GENERAL: No chills, fever, n0 weight l0ss, fatigue or weakness.

HEENT: Eyes: Patient has no blurred vision, no visual loss, no yellow sclera or double vision.

Ears, warn to touch, canal is red with noted fluid behind the tympanic membrane.

Nose and throat: No congestion, sneezing, sore throat or runny nose.

SKIN: Tanned and no pain.

CARDIOVASCULAR: No discomfort of the chest, no pressure or chest pain. Negative for edema or palpitations.

RESPIRATORY: Patient has no sputum or cough, no breath shortness.

GASTROINTESTINAL: No blood or abdominal pain. Patient has no diarrhea or vomiting, nausea, anorexia.

GENITOURINARY: No frequency, nocturnal enuresis or burning

NEUROLOGICAL: No change in bladder or bowel control. No dizziness, headache, syncope, ataxia, paralysis, tingling or numbness in the extremities.

MUSCULOSKELETAL: Patient has no back pain, muscle pain, stiffness or joint pain.

HEMATOLOGIC: Patient has no anemia.

LYMPHATICS: Not indicated

PSYCHIATRIC: No anxiety or depression history.

ENDOCRINOLOGIC: Not indicated

Physical exam: Using a pneumatic otoscope, patient ear canal was examined, noted redness of the canal and fluid behind the tympanic membrane. The pneumatic otoscopy is especially used to distinguish between a red tympanic membrane caused by disease from that which is brought about by crying (it will show a mobile membrane), there will be no movement (Ball et al., 2019 Focused Ear Examination Soap Note Sample).

Diagnostic results: Acute Otitis externa.

Differential Diagnoses

Acute Otitis externa, it is also referred to as ‘swimmer’s ear’, it’s a common illness of adults adolescents, and children. The unique structure of auditory canal adds to the otitis externa development given that the external auditory canal is dark, warm and prone to become moist, making it an perfect environment for fungal and bacterial growth (Mustafa, 2015).

According to the AAOHNS (American Academy 0f Ot0laryng0l0gy – Head and Neck Surgery), this disease is painful resulting from infection, irritation, or inflammation,” (Healthline, n.d.). It is often cause by increased moisture from water trapped in the ear, which allows bacteria normally found in the ear to grow.

Otitis media with effusion (OME): This presents with a non-purulent effusion in the middle ear that may be either serous or mucoid. Symptoms depicted include aural fullness or hearing loss but typically do not involve fever or pain. (Higgins, 2019).

The primary course of OME is said to involve an obstructive lesion around the tubotympanic cleft including the mastoid and the epitympanum, thus resulting in negative pressure in the middle part of the ear leading to dysfunction of the Eustachian tube (Higgins, 2019). With Otitis media with effusion patients feel a cracking sound in yawning or swallowing along with a feeling of fullness and discomfort in the ear. There is an additional effusion in the middle ear (Ball et al., 2019).

Acute Otitis media: This is an acute middle ear infecti0n that usually lasts for 6 weeks or less. The major cause is Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae, which find their way in the middle ear after the dysfunction of the eustachian tube brought about by obstruction related to surrounding structures inflammation and upper respiratory infections. It manifests with pain in the ear, fever and difficulty in hearing.

Usually happens as a complication of infection of the viral upper respiratory tract (Nokso-Koivisto, Marom, & Chonmaitree, 2015). Also, it was found that acute otitis media is one of the majo diseases in kids and the most frequent reason for antimicrobial prescriptions in most countries (Nokso-Koivisto et al., 2015). The patient did not have any history of any recent upper respiratory infection.

Mastoiditis– It is also similar to otitis media, infection of middle ear. The mastoid bone is in the form of air sac and to function it receives air from the eustachian tube. In case an infection develops in the middle ear and the eustachian tube is blocked, it leads to the mastoid bone infection referred to as mastoiditis. Mastoiditis symptoms are almost same as an ear infection which includes pain in the ear, headache, fever, hearing loss in the affected ear, swelling, redness in the affected ear (Healthline, n.d.).

Bullous Myringitis – Is an infection involving the ear drum that begins with a head cold characterized by reddish blisters on the ear drum. It also causes significant pain in a patient (Kaldırım, Tuncer, Durusu, Eroğlu & Erkencigil, 2013). No blisters where seen during ear assessment.

Cholesteatoma: A cholesteatoma is a cyst-like mass of the middle ear or mastoid cavity. It can be caused by chronic otitis media due to prolonged granulation of scar tissue. It is known to cause hearing loss due to obstruction (Dains, Baumann, Scheibel, 2016).

Labyrinthitis: Labyrinthitis is an inflammation of the inner ear and is usually related to a coexisting bacterial or viral infection. It causes severe vertigo and can be a complication of otitis media. Labyrinthitis can result in hearing loss (Ball et al., 2019).

Foreign Body: A foreign body in the ear canal is more common in younger children and can result in ear pain and hearing loss (Ball, et al., 2019).

References for Focused Ear Examination Soap Note Sample

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to

physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Healthline (n.d.) Mastoiditis. Retrieved from https://www.healthline.com/health/mastoiditis

American Academy of Otolaryngology Head and Neck Surgery, (AAOHNS). (n.d.). Swimmer’s ear. Retrieved from http://www.entnet.org/content/swimmers-ea

Higgins, T. S. (2019, May 30). Otitis Media With Effusion. Retrieved from https://emedicine.medscape.com/article/858990-overview

Nokso-Koivisto, Marom, & Chonmaitree, (2015). Acute Otitis Media-pathophysiology, symptoms, management, nursing management. Retrieved from http://www.nsgmed.com/ent-ear-nose-throat/acute-otitis-media-pathophysiology-symptoms-management-nursing-management/

Kaldırım, U., Tuncer, S., Durusu, M., Eroğlu, M., & Erkencigil, M. (2013). Bullous myringitis: A cause of hearing loss. African Journal Of Emergency Medicine, 3(4), 17-18. http://dx.doi.org/10.1016/j.afjem.2013.08.045

Mustafa, M. (2015). Acute Otitis Media-pathophysiology, symptoms, management, nursing management. Retrieved from http://www.nsgmed.com/ent-ear-nose-throat/acute-otitis-media-pathophysiology-asymptoms-management-nursing-management/

Focused Nose Examination

Patient Information:

Mr. Richard., 50-yrs-old, Male

CC: ”Congestion, Sneezing, Rhinorrhea, Post-Nasal Drainage, and has had an itchy nose, eyes, palate, and ears x 5 days”.

HPI: The individual patient (Richard) is a 50 year-old-male who presented with sneezing, congestion, post-nasal drainage, and rhinorrhea that began 5 days ago. The patient also says that he has an itchy n0se, eyes, palate, and ears that began 5 days ago. The patient reports consuming Mucinex OTC to assist with breathing at night with minimal relief. Patient denies complaints of headaches or pain.

Location: nose, eyes, palate, ears

Onset: 5 days ago

Character: congestion, sneezing, rhinorrhea, post-nasal drainage

Associated signs and symptoms: itching of the nose, eyes, palate, and ears

Timing: reported to have started 5 days ago

Exacerbating/ relieving factors: patient consumed Mucinex OTC for the past two nights with minimal relief of symptoms

Severity: no severity reported

Current Medications: Mucinex OTC, 1-2 tabs by mouth nightly the past two nights.

Allergies: NKDA.

PMHx: No significant medical history reported. No report of significant medical history, illnesses, or surgeries. Patient also does not report his history of immunizations.

Soc Hx: No social history reported.

Fam Hx: Patient did not report on family history.

ROS:

GENERAL: Patient is alert and oriented Negative for weight loss, chills. Appears anxious and tired from lack of sleep.

HEENT: Negative for headache or pressure. Positive for itching in eyes. Negative for vision loss or blurring. Positive for itching in ears. Negative for hearing loss, ringing. Positive for congestion, pressure, and itching in nose. Positive for difficulty breathing while sleeping, boggy nasal mucosa with clear and thin drainage. Positive for enlarged nasal turbinate. Positive for erythema in throat. Negative for enlarged tonsils or dysphasia.

SKIN: No rash, itching or burning. No change in skin pigmentation.

CARDIOVASCULAR: No discomfort of the chest, pressure or chest pain. No edema or palpitations.

RESPIRATORY: Patient has no sputum or cough, no breath shortness.

GASTROINTESTINAL: No blood or abdominal pain. Patient has no diarrhea or vomiting, nausea, anorexia.

GENITOURINARY: No frequency, nocturnal enuresis or burning

NEUROLOGICAL: No change in bladder or bowel control. No dizziness, headache, syncope, ataxia, paralysis, tingling or numbness in the extremities..

MUSCULOSKELETAL: Patient has no back pain, muscle pain, stiffness or joint pain.

HEMATOLOGIC: Patient has no anemia, bleeding or hematoma.

LYMPHATICS: Patient has no inflamed or enlarged nodes.

PSYCHIATRIC: Patient has no depression

ENDOCRINOLOGIC: Negative for rep0rts 0f sweating, c0ld 0r heat int0lerance.

ALLERGIES: N0 hist0ry 0f asthma, inflammation, 0r eczema. Positive for rhinitis.

Physical exam:

General: Oriented and alert x 4, denies chills, fever. Negative for acute distress.

Head: Normocephalic, symmetrical facial features.

EENT:

Eyes: PERRLA with EOM intact. Positive for itching of the eyes. Negative for photophobia or purulent drainage.

Ears: Positive for itching. Negative for lesions, tenderness, or loss of hearing. Negative for excess cerumen or damage to ear canals.

Nose: Positive for paleness and bogginess. Positive for itching, congestion, enlarged nasal turbinates, and clear nasal drainage. Negative for difficulty with smell.

Throat: Positive for itching and erythema. Negative for tonsil enlargement.

Neck: Trachea is midline. Negative for tracheal deviation.+

Cardiac: Rate and rhythm regular. No evidence of murmur. Radial and pedal pulses are 2 + bilaterally. No evidence of peripheral edema.

Respiratory: Lungs are clear with respirations even and unlabored with adequate chest expansion.

Musculoskeletal: . Full range of motion in extremities. Strength equal and strong in upper and lower extremities bilaterally.

Diagnostic testing/exams results:

The first testing to order should be to obtain a nasal smear to assess for allergic rhinitis or sinusitis (Dains, Baumann, & Scheibel, 2019). By examining the cellular substances of the nasal exudations, one may possibly find polymorphonuclear cells and bacteria in sinusitis (Radojicic, 2017). In a viral infection, these would not be discovered, and in allergic disorder, one would anticipate finding eosinophils (Radojicic, 2017).

Another diagnostic test to be performed would be the Allergen Specific-IgE. Ascertaining the existence 0f l0cal SE-specific IgE is als0 imp0rtant diagn0stically, as it w0uld be linked t0 the devel0pment 0f asthma als0 (De Schryver et al., 2015). Determining indicat0rs like IgE in muc0sal tissue is the m0st direct examinati0n 0f inflammati0n in the nasal cavity (De Schryver et al., 2015). In practice, h0wever, c0llecti0n 0f tissue is 0nly sensible when the patient requires surgery, as sinus muc0sa bi0psy is an invasive pr0cedure (De Schryver et al., 2015).

Other testing to consider is a prescription of a therapeutic trial testing of intranasal corticosteroids versus antihistamines for allergic rhinitis n0t caused by an allergy. N0n-allergic rhinitis is a chr0nic illness 0f the n0se, that is n0t triggered by infecti0n 0r allergies. Patients with n0n-allergic rhinitis enc0unter sympt0ms that alter their quality 0f life, such as nasal c0ngesti0n, runny n0se and sneezing (Segboer et al., 2019). It can be used in moderate to severe allergic rhinitis and a trial of intranasal corticosteroids should be considered a primary choice, especially if obstruction of the nasal cavity is known to be an issue (Meltzer, 2013).

Differential Diagnoses:

Allergic Rhinitis: Allergic rhinitis is recognized by a recurrent rhinorrhea with clear watery nasal drainage, wheezing, and itching (Ball, 2019). Nasal turbinates are found to be pale and edematous (Dains, Baumann, & Scheibel, 2019). Approximately 25% of the populace has a few sort of hypersensitivity. Diagnosis of IgE mediated responses to allergens in the air is established on a combination of history, physical examination, and skin tests (Ball, 2019).

Nasal smears can be attempted for the imminence of eosinophils to affirm an allergenic reaction (Dains, Baumann, & Scheibel, 2019). Allergic rhinitis and asthma often accompany one another, and it is unclear if it a trigger alone (Delves, 2018). A trial of intranasal corticosteroids and antihistamine, a nasal smear, and positive skin testing can confirm diagnosis along with diagnostic testing of the Allergen Specific-IgE.

Acute Sinusitis: Sinusitis is distinguished by the lining inflammati0n 0f the paranasal sinuses. This is due to the fact that the nasal mucosa is c0ncurrently inv0lved and because sinusitis rarely 0ccurs with0ut parallel rhinitis, rhin0sinusitis is n0w underst00d as the term f0r this c0nditi0n (Brook, 2018). The determination of a diagnosis of acute sinusitis is not likely for the patient because of a lack of an infectious cause.

Acute Otitis media: It has some symptoms such as fever that are similar with rhinitis. This is an acute middle ear infection that usually lasts for 6 weeks or less. The major cause is Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae, which find their way in the middle ear after the dysfunction of the eustachian tube brought about by obstruction related to surrounding structures inflammation and upper respiratory infections.

It manifests with pain in the ear, fever and difficulty in hearing. Usually happens as a complication of infection of the viral upper respiratory tract. Also, it was found that acute otitis media is one of the major diseases in kids and the most frequent reason for antimicrobial prescriptions in most countries (Nokso-Koivisto et al., 2015).

Common Cold: The common cold is recognized as the rhinovirus. Most frequently, it is transferred t0 susceptible individuals thr0ugh direct c0ntact 0r by spread 0f aer0s0l particles (Buensalido, 2019). The main site 0f in0culati0n is the nasal muc0sa, th0ugh the c0njunctiva may be inv0lved t0 a lesser extent (Buensalido, 2019). The virus attaches t0 respirat0ry epithelium and spreads l0cally (Buensalido, 2019). The diagnosis of the common cold is unlikely the appropriate diagnosis for the patient due to the lack of physical findings in the assessment and diagnostic testing.

Mastoiditis– The mastoid bone is in the form of air sac and to function it receives air from the eustachian tube. In case an infection develops in the middle ear and the eustachian tube is blocked, it leads to the mastoid bone infection referred to as mastoiditis (Dains, Baumann, & Scheibel, 2019). Mastoiditis symptoms are almost similar to rhinitis which includes, headache, fever swelling, redness and all inflammation symptoms.

References

Brook, I. (2018, March 1). Acute sinusitis. Retrieved from https://emedicine.medscape.com/article/232670-overview

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Buensalido, J.A.L. (2019, July 30). Rhinovirus (RV) infection (common cold). Retrieved from https://emedicine.medscape.com/article/227820-overview

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Delves, P.J. (2018). Allergic rhinitis. Retrieved from https://www.merckmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/allergic-rhinitis

De Schryver, E., Devuyst, L., Derycke, L., Dullaers, M., Van Zele, T., Bachert, C., & Gevaert, P. (2015). Local immunoglobulin e in the nasal mucosa: clinical implications. Allergy, Asthma & Immunology Research, 7(4), 321–331. https://doi-org.ezp.waldenulibrary.org/10.4168/aair.2015.7.4.321

Meltzer, E. O., Schatz, M., Nathan, R., Garris, C., Stanford, R. H., & Kosinski, M. (2013). Reliability, validity, and responsiveness of the rhinitis control assessment test in patients with rhinitis. Journal of Allergy and Clinical Immunology, 131(2), 379-386. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1016/j.jaci.2012.10.022

Radojicic, C. (2017). Sinusitis. Retrieved from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/allergy/rhino-sinusitis/Default.htm

Segboer, C., Gevorgyan, A., Avdeeva, K., Chusakul, S., Kanjanaumporn, J., Aeumjaturapat, S., Reeskamp, L.F., Snidvongs, K., & Fokkens, W. (2019, November 2). Intranasal corticosteroids for non-allergic rhinitis. Retrieved from https://www.cochrane.org/CD010592/ENT_intranasal-corticosteroids-non-allergic-rhinitis