physical assessment10

3

Student Name

Rasmussen University

COURSE#: NUR2180 Physical Assessment

Instructor:

October 24, 2021

Physical examination of the ear.

Subjective Information

A 83 year old male is in an assistive living facility comes to the nursing station and is C?O pain. He states increased pain in his right ear and decreased hearing. He denies ear discharge. He endorses vertigo for seven months that is precipitated by certain changes in head position. His weight is down 5 pounds since last weak to 105 pounds. His vitals are 144/82, HR63, temp 99.0, RR16, and 2 sat of 97% on room air. The client indicated that he has been experiencing pain for the last six months. After four months, he started developing some difficulty in hearing. When asked if he was under any medication, the client denied being on medication before. Also, he stated that once he visited a doctor and he was given a five-day antibiotic. He has no history of radiation or x-ray of his ear. He only indicated that he has been using painkillers, especially when overwhelmed by pain. Besides, he indicated that he is allergic to some food especially spiced food and protein-related products. On a scale of 1-10, the client indicated that his score regarding ear pain was 8 out of the maximum 10.

Moreover, the client indicated pain when chewing. The pain had been the same when he was diagnosed with gastrointestinal reflux. The patient had been diagnosed with mild sinusitis but got well after a doctor’s medical examination and drug prescription. The pain that he had been experiencing was continuous, and the aggravating factors included cold, chewing, and a noisy environment. The client uses alcohol but not frequent while he does not smoke at all.

Objective Information

The client was asked to localize the pain, and he pointed at the Temporomandibular Joint. On inspection of the auricle and the periauricular region, middle ear effusion had moderate to severe bulging of the regions around the tympanic membrane. Examination of the external auditory canal showed that the ear canal was symmetrical, reddish, swelling, inflammation, and the pain reported severe pain in this region. Palpation of the crepitus of the temporal mandibular paint showed discomfort in the patient. Palpation of the oral cavity, especially the molars that have been linked to radiating pain to the air, showed that the molars were intact and had no cause of alarm. Evaluation of the oropharynx was normal with no sign of sepsis or inflammation in these parts. Lastly, the physical examination of the face showed facial weakness within the forehead that was accompanied by unremarkable examination.

Risk Factors

Based on the evaluation of the symptoms and the objective examination findings, the client is suffering from secondary Otalgia and not primary Otalgia (Kim et al., 2015). The diseases significantly affect persons above fifty years because persons above fifty years are prone to age-related complications such as coronary artery attack and diabetes (Earwood et al., 2018). In addition, immune-compromised persons such as those living with HIV aids and those who use alcohol and have low body weight are at higher risk of Otalgia disease (Earwood et al., 2018). Excessive smoking and alcohol consumption increase the probability of cancer and tumors affecting the head, neck, and esophagus cancers, and it contributes to pain in the patient ear (Harrison and Croin, 2016).

References