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Nursing Health Assessment of Documentation Record 212 & 213 Your Name:__Caitlin Bourke__ System Being Assessed ___the

e ear___

HPI & CC How have you been lately? Pt states she has been healthy the past 6 months. 3 days ago pt states she developed an earache.

CC: I have an earache.

O 3 days ago L Point to the inside of her ear canal (L ear) D States the pain is almost constant C States it is an aching, throbbing pain A States eating/chewing/wind aggravate it; laying down alleviates it slightly R States she has itching and popping in her ear; feels ill T States she has not tried any meds or therapies; she just rests S States the pain is an 8/10. States it has interfered with her ADLs greatly

Medications: (Prescribed, OTC, Herbals) Centrum MultiVit. 1 Tab QAM, Depo-Provera 104mg/0.65mL SQ Q3months, Allerga 60mg tab BID

Allergies: (Drugs, Food, Environment) States she has seasonal allergies. States is allergic to pollen, dust, and ragweed. Denies allergies or sensitivities to any foods, drugs (legal&illegal), latex, adhesives, iodine, nickel/metals, detergents.

PMH: (include diagnostics where applicable) Denies any Hx of problems or injuries to her eyes, ears, nose, head, or neck. Denies any Hx of chronic ear, eyes, or throat infections. States had chronic sinus infections as a child (approx. ages 10-18), yet has had no problems since.

PSH: (Past Surgical History) Tonsillectomy 2001. Appendectomy 2004.

FH: (At least 2 Blood relative generations) Denies any family Hx of sensorineural hearing loss and conductive hearing loss. States paternal grandparents wear hearing aids, starting at the ages 78, 82. States mother has cancer of the thyroid. Denies any other cancer in family.

Social History: (ETOH, Smoke, Recreational Drugs) Denies use of tobacco and recreational drug use. States drinks alcohol approx. 3xs Qmonth. States exercises for 30mins 5xs Qweek. Denies any contact to loud occupational, environmental, or social(music) noises.

General Survey: Pt appears states age. Pt sitting upright, leaning to L side with hand over L ear. Pt appears to be grimacing. Pt is pale and appears nervous. Pt can have conversation and is able to hear during.

Use the following techniques to perform the physical assessment: Inspect Palpate Auscultate & Percuss Use anatomical landmarks to describe the exact location of an area of concern. Hearing present with conversation. Pinna aligned with outer canthus of eye bilat. No nodules, cysts, edema, or hematoma present. No discomfort or discharge noted upon palpation. Ears are symmetric bilat. Canal appears patent without odor, without foreign objects. Minimal flakey cerumen noted in auditory canal. TM is pearly gray, no bulging or perforations noted. Cone of light reflex present. Whispered words were repeated back 80% correctly. Tone in Weber Test heard bilat. Rhinne Test AC/BC 2:1.