Clinical Summary Assessment

Improved Essays
- Complete a thorough assessment based on the patient’s chief complaint and risk factors.

Should include: inspection, palpation, percussion and auscultation where appropriate and the special tests as required based on the chosen system.

- It is not necessary to include how the assessment was performed, rather describe the normal and abnormal findings that you observed for the chosen system.

Inspection:
Inspection of the ears: Both ears are present, are both of equal size with no presence of swelling or thickening. Colour of left ear is consistent with the patient’s facial skin colour. Both ears are symmetrical and are both aligned with the outer canthus. Redness apparent on the right ear. Bilaterally the skin on both ears is intact with no lumps or lesions. Small amount of yellow discharge present in right ear, left ear free of
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Eardrum is shiny and translucent with a pearly grey colouration. Light reflex is at position at 7’oclock. Malleus clearly visible
Ear canal of right year presence with some redness and swelling. Tympanic membrane appears amber yellow in colour, ear drum appears to be bulging and light reflex seems to be distorted.

Nasal cavity assessed; bilaterally in the nasal cavity both nasal mucosa were moist and pink in colour, no presence of bleeding, no foreign objects.

Hearing test
Whisper test: with right ear covered, patient was asked to repeat the letters “house”, “school”, “Monday” and “twenty”. Patient could repeat without any difficulties indicating no hearing impairment of left ear. Procedure repeated with right ear, evidence of difficulty repeating words indicating decrease hearing in the right ear.

Tuning fork: Hearing in the left ear is intact, air conduction time is twice as long as bone conduction time. Right ear shows presence of conductive hearing loss where the bone conduction time is longer than the air conduction

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