You are treating a 62-year-old female patient who complains of ear pain and discomfort, sometimes accompanied by what are described as “weird sounds” in one ear
Case study HEENT
Instructions
The case study requires the student to read, analyze, and make clinical decisions, based on the information provided. Please make sure that the following be included with each case study:
• Positive findings from the physical exam provided.
• Anticipatory guidance should always be given.
• If a prescription is needed, one must be provided. See prescription template in the SOAP note.
• Include the Primary diagnosis (and any secondary diagnoses if applicable)
• Include two differential diagnoses.
• Each diagnosis provided should have a rationale, supported by evidence from the literature, as to why it is included in the list.
• The Treatment and management must also be accompanied by a rationale and support from the literature as to why it was chosen.
• Answer additional questions, as indicated in the Case Study Prompt.
• APA citations of resources used.
Case Study Prompt:
You are treating a 62-year-old female patient who complains of ear pain and discomfort, sometimes accompanied by what are described as “weird sounds” in one ear. The patient denies any vertigo, nausea, or vomiting. She also reports feeling tired throughout the day and notes that all the symptoms worsen at night. She also notes that she finds it difficult to sleep at night and has difficulty concentrating, which she attributes to the lack of quality sleep at night.
Case Questions:
1. You suspect tinnitus as a potential diagnosis. What other questions would you ask the patient to determine the validity of this diagnosis?
2. What objective assessments are included in the evaluation of the clinical presentation?
3. Laboratory tests are necessary to confirm possible underlying causes of tinnitus. Which tests should be considered and why?
4. How might a differential diagnosis alert you to the underlying cause of tinnitus?
5. Is a referral to an otorhinolaryngologist indicated for this patient?
6. What type of education should be provided to the patient to help minimize the symptoms of tinnitus?
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