Documentation of the Problem-based Assessment of the Head, Ears, and Eyes
Name
Institution
Date
Documentation of Problem-based Assessment of the Head, Ears and Eyes
Subjective
Mr. Smith a 26 years old Caucasian male presents to the office with pain and pus draining from the ear. He also mentions being experiencing a fever. He is a part-time swimming trainer and swimming is his major hobby. He is a third born in a family of five. He denies any use of drugs or alcohol. He enjoys support from both family and friends. He has been on Tylenol for the last 24 hours to ease pain and lower the fever.
Location: Ear
Onset: 4 days ago
Character: Radiating
Associated signs and symptoms: Fever, itching, redness of the skin around the ear
Timing: All the time
Exacerbating/relieving factors: Pain killer
Severity: 9/10 scale
Current Medications: Over the counter Tylenol
Allergies: No known drug or food allergies.
Objective
Vital signs: BP 140/80, P 70, Weight 130, Height 4’3″
Ears: Drainage from the ear, redness of the outer ear, itchiness, pain, swollen ear canal, conductive hearing loss
Head: swollen neck glands
Eyes: No blurred vision, no redness,
Potential Risk factors
Excess moisture in the ear canal
An individual might have excess moisture in the ear canal emanating from heavy perspiration, water getting trapped in the ear after swimming, or prolonged humid weather. A moist environment is conducive for the growth of bacteria and in rare cases the growth of fungus.
The use of cotton swabs or fingers
The cleaning of the ear with cotton swabs or fingers may interfere with the amount of wax in the ear canal. A lack of ear wax has been shown to contribute to the development of swimmer’s disease. Ear wax acts as a barrier against bacteria growth and moisture.
Ear devices
Ear devices like hearing aids, earbuds and hearing aids can cause tiny breaks in the skin providing a favorable environment for bacteria growth.
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