Soap Note Ear Cholesteatoma Assignment

 Soap Note Ear Cholesteatoma Assignment

 Soap Note Ear Cholesteatoma Assignment

Patient Information:

J, 15years, Male, Hispanic

S.

CC “I have a mild earache.”

HPI: Mr. J is a 15-year-old Hispanic male who walked in the clinic complaining about a mild earache, which started three days ago. The associated symptoms included pain in the right ear, fever, and difficulty hearing from the right ear. The symptoms become even worse when the patient sleeps.

Current Medications: The patient uses Aspirin and Ibuprofen to relive pain if need be.

Allergies: No history of any allergic reactions.

PMHx: The patient has no history of acute otitis media but was admitted some months back with an underlying loss of hearing. Besides, patient had not suffered from tonsillectomy or adenoidectomy in the past but completed the medication given when he was admitted.

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Soc Hx: The patient accepted more time swimming during summer and denies any physical injury on the affected ear.

Fam Hx: The patient has an uncle suffering from hearing loss.

ROS:

GENERAL: The fever, general itchiness in the ear, regular swimming habits, and no use uses earplugs. The patient uses earbuds in cleaning the ear.

HEENT: Ear: Pain from the right ear and hearing loss, denies tinnitus and vertigo but accepts discharge from the ear and itchiness. Eye: denies any pain or congestion. Throat: denies any complaints of sore throat.

RESPIRATORY: Denies having any sputum production or post-natal discharge and the color of the mucus was normal.

ALLERGIES: Denies any form of allergic reactions.

O.

Height 87 cm, wt, 50 kg,

Vital signs: Temp; 97 F, RR;17, pulse 79, BP; 120/80 mmHg.

General: A well-oriented patient with no notable acute health problem

Head: normal

Eyes: normal

Ears: inflammation and blocked tympanic membrane.

Nose: the nasal mucosa pale and boggy, and the septum midline.

Throat: Inside of the mouth lesions, swellings of tonsils observed.

Neck: No infraclavicular lymphadenopathy, smooth thyroid.

Respiratory: No infection in the upper respiratory infection and clear lungs

Diagnostic results: Failed the whispered voice, Weber test showing a unilateral loss, Failed Rinne test showing that the patient cannot hear a sound conducted through the air.

A.

Differential Diagnoses

1. Cholesteatoma: This is the growth of a skin tag inside the ear and behind the eardrum. The patient can be born with this problem or develop the problem from several ear infections (Udayabhanu et al., 2018). It is imperative to know if the patient has had several infections in the past.
2. Otitis media: This is an infection in the middle ear that always presents unilaterally when hearing loss is present. The tympanic membrane is always pink. Pus forms inside the ear, which could result in a tympanic membrane (Mather et al., 2020). Pain in the ear, fever, difficulty hearing, irritability, and lethargy.
3. Eustachian catarrh: Results from an upper respiratory infection. It would be important to know if the patient suffers from an upper respiratory tract infection (Mather et al., 2020). The fluid collects in the Eustachian tube, which could cause trouble in hearing.

Cholesteatoma

This patient needs a minor surgery to make the cholesteatoma go away. However, the patient can use fluoroquinolone as an antibiotic to manage the condition as they plan for the surgery. The most effective method to solve the Cholesteatoma method on the patient is by arranging for it to be surgically removed (Udayabhanu et al., 2018). The removal of the cysts will prevent other complications that can occur; in any case, the cysts will grow even larger. Cholesteatoma cannot go away naturally, and its growth would cause additional problems for the patient. For follow-ups and check-ups, the patient should visit the clinic every week to monitor the healing process.

Otitis media

This patient needs a clinical approach to treat and manage this condition. The patient can be given a daily dose of amoxicillin for ten days. This is the first-line antibiotic therapy used in such conditions. However, this treatment is not recommended for children suffering from purulent conjunctivitis. The patient needs to be educated and informed to refrain from exposing themselves to cigarette smoke and improve the general cleanliness of the ear (Mather et al., 2020). These therapies would enhance the healing of the patient and limit further exposure to the risk factors of the infection. Regular check-up in the first three months is needed for the patient to ascertain the process of healing and the effect of the administered treatment on the patient.

Eustachian catarrh

This condition often goes away naturally without major clinical treatment. The patient can do more exercises to open up the tubes. The activities can include yawning, chewing gum, or swallowing. Besides, jumping and taking pushups also is effective in opening up the tube. The patient can help relieve the ear by taking a deep breath, pinching closed nostrils, and blowing with the mouth shut. If these measures do not take the problem away, the patient needs to use a decongestant that would reduce the swelling of the lining within the tubes (Raymond et al., 2022). The patient can be signed for a minor surgery that would lead to creating an incision in the eardrum and suctioning out the fluid from the middle of the ear. This process will give the Eustachian tube lining tube about one to three days to heal. The patient needs to be educated and informed to on the need to swim cautiously and limit positions that might allow water into the ear. Besides, he needs to learn effective therapies that can aid in removing the fluid from the ear immediately after swimming.

References

Mather, M., Powell, S., Yates, P. D., & Powell, J. (2020). Acute mastoiditis in children: contemporary opportunities and challenges. The Journal of Laryngology & Otology, 134(5), 434-439. https://doi.org/10.1017/S0022215120000833

Raymond, M. J., Shih, M. C., Elvis, P. R., Nguyen, S. A., Brennan, E., Meyer, T. A., & Lambert, P. R. (2022). A Systematic Review of Eustachian Tube Procedures for Baro‐challenge Eustachian Tube Dysfunction. The Laryngoscope. https://doi.org/10.1002/lary.30132

Udayabhanu, H. N., Prasad, S. C., Russo, A., Grinblat, G., & Sanna, M. (2018). Cholesteatoma of the external auditory canal: review of staging and surgical strategy. Otology & Neurotology, 39(10), e1026-e1033. doi: 10.1097/MAO.0000000000001972

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Provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up