Case 1: Jonas is a 22-year-old athlete who presents with complaints of irritation and fullness in his right ear. He has been training for six hours a day, including swimming, running, cycling, and weightlifting. He is concerned that the fullness in his ear and the irritation could require him to limit his training. He denies any recent upper respiratory infections, nausea, vomiting, or dizziness.
1. Discuss what questions you would ask the patient (One paragraph)
a. What physical 3xam elements you would include
b. what further testing you would want to have performed.
2. In SOAP format, list:(One paragraph)
a. Pertinent positive findings that validate your main diagnosis
b. Pertinent negative findings that make you think of other differential diagnoses
3. Treatment plan, including: (One paragraph)
a.Pharmacotherapy with complementary
b. OTC therapy
c. Diagnostics (labs and testing)
d.Health education and lifestyle changes
e. Age-appropriate preventive care
f. Follow-up to this visit.