Case Study: Patient Evaluation Plan

Case Study: Patient Evaluation Plan

Patients present to healthcare institutions with different complaints and health needs, requiring nurses to evaluate them for diagnosis and treatment planning. Patient evaluation is an assessment whereby a care provider discusses the patient’s needs and collects subjective and objective data for diagnosis and treatment planning. This discussion presents a patient evaluation plan, the assessment tools used, and immunizations related to health promotion and disease prevention for the patient in the case study. The case study involves Mr. Abrams, a 69-year-old who has been referred to the clinic for a hearing evaluation. He complains of an inability to hear much of the conversation on the television. In addition, he has worked in a printing company for 35 years and is still working part-time. His wife adds that he cannot hear her at home.

The evaluation plan for this patient will entail patient information gathering, review of systems pertinent to the chief complaint, physical assessment/examination, and diagnostic tests based on the physical exam findings. In the patient information gathering, I would gather demographic and contact information for patient registration and identification purposes. I would also allow the patient to describe the reason for seeking medical help, the chief complaint, and the related issues, such as onset, duration, and severity of presenting symptoms. The other information would include the patient’s medical, social, and family history.

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Following information gathering, I would review the systems pertinent to the chief complaint. In this case, the chief complaint is hearing loss. The systems pertinent to the complaint are (Head, Eyes, Ears, Nose, and Throat) HEENT, cardiovascular, and neurological systems. On the HEENT, a particular focus would be on the ears. Specific questions would include whether the patient is experiencing ear pain, discharge, and ringing in the ear. The cardiovascular and neurological systems would be reviewed to identify whether the underlying cause of the hearing loss could be related to circulation or nerve-related problems.

The third step in the patient evaluation plan is performing a physical assessment of the ears. The physical assessment entails the external ear assessment through observation and inspection and the internal ear assessment using an otoscope. Observing the external ear for abnormalities, deformities, lesions, tenderness, inflammation, and symmetry is essential. In addition, considering the patient has a history of cerumen impaction, it is important to inspect whether there is cerumen buildup in the external auditory canal. In the internal ear examination, I would check out for blockages, infection signs, tympanic membrane perforation, or scarring.

Furthermore, I would perform further tests to assist in diagnosis. The hearing assessment tools I would use for the patient in this case include a tuning fork test, audiometry, and the Hearing Handicap Inventory for the Elderly (HHIE). According to Naccarato and Wilson (2022), the tuning fork test is effective in differentiating between sensorineural hearing problems and unilateral conductive hearing loss. An audiometry test would help determine the type and severity of hearing loss (Erwin & Chen, 2023). In a study by Chayaopas et al. (2021), the HHIE tested effective in screening elderly adults for hearing loss. Therefore, the selected hearing loss assessment tools are suitable for this patient and do not pose further issues for the patient.

However, additional factors might present issues when performing the physical assessment and tests. Erwin and Chen (2023) note that assessing hearing problems among elderly adults may have different challenges, including cooperation. Due to issues such as age and education, elderly patients, such as the patient in this case study, may fail to cooperate during the tests, thus limiting the tests and leading to failure to use evaluation tools such as hearing loss questionnaires, which would also be effective in identifying the diagnosis. Therefore, the nurse should select the evaluation tool that best suits the individual patient’s needs and other factors such as age and education.

In addition, the treatment plan developed after diagnosing the patient should be accompanied by patient education and health promotion for disease prevention. In this case, the immunization requirements relevant to the patient include the pneumococcal vaccine, which is recommended for all elderly patients aged 65 and above. In addition, the patient should be encouraged to get a flu vaccine. Adults aged 65 and above are known to be at a higher risk of developing flu and its complications (Conrad et al., 2023). These immunizations will help the patient prevent related conditions that adversely affect elderly adults.

Patient education for a hearing loss elderly patient aims at enabling the patient to evaluate the condition. Chandrasekhar et al. (2019) note that the essence of follow-up should be emphasized to hearing loss patients. In addition, the nurse should help the patient understand their hearing aids and the benefits of using them appropriately. In addition, the patient should be educated on appropriate ear protection, including avoiding excess noise, to prevent worsening hearing loss.

Patient evaluation planning is vital in careful diagnosis and treatment planning. The patient evaluation plan explained above entailed gathering patient information, reviewing systems pertinent to the chief complaint, physical assessment/examination, and diagnostic tests. The selected evaluation tests are appropriate for the patient’s population. The relevant patient education and health promotion content for this patient included immunizations, follow-up, and appropriate ear care.


Chandrasekhar, S. S., Tsai Do, B. S., Schwartz, S. R., Bontempo, L. J., Faucett, E. A., Finestone, S. A., Hollingsworth, D. B., Kelley, D. M., Kmucha, S. T., Moonis, G., Poling, G. L., Roberts, J. K., Stachler, R. J., Zeitler, D. M., Corrigan, M. D., Nnacheta, L. C., & Satterfield, L. (2019). Clinical Practice Guideline: Sudden Hearing Loss (Update). Otolaryngology–head and neck surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery161(1_suppl), S1–S45.

Chayaopas, N., Kasemsiri, P., Thanawirattananit, P., Piromchai, P., & Yimtae, K. (2021). The effective screening tools for detecting hearing loss in elderly population: HHIE-ST Versus TSQ. BMC geriatrics21(1), 37.

Conrad, A., Valour, F., & Vanhems, P. (2023). Burden of influenza in the elderly: a narrative review. Current Opinion in Infectious Diseases36(4), 296–302.

Erwin, D.Z. & Chen, P. (2023). Hearing Loss in the Elderly. In: StatPearls [Internet]. Retrieved from:

Naccarato, A., & Wilson, C. (2022). Assessment of Vision and Hearing in Older Adults. Home Healthcare Now40(5), 279–280.


Below is a case study to use for this Discussion. Based on the provided information, review the case study and think about a possible patient evaluation plan. As part of your evaluation planning, consider where the evaluation would take place, whether any other professionals or family members should be present, appropriate assessment tools and guidelines, and any other relevant information you may wish to address.

Consider whether the assessment tool you identified was validated for use with this specific patient population and if this poses issues. Think about additional factors that might present issues when performing assessments such as language, education, prosthetics, missing limbs, etc.

Consider immunization requirements that may be needed for this patient.

Post an explanation of your evaluation plan for the patient in the case study provided, and explain which type of assessment tool you might use for the patient. Explain whether the assessment tool was validated for use with this patient’s specific patient population and whether this poses issues. Include additional factors that might present issues when performing assessments, such as language, education, prosthetics, etc. Also explain the immunization requirements related to health promotion and disease prevention for the patient.

Mr. Abrams, a 69-year-old man, was referred to your office for a hearing evaluation. He continues to work in a printing company, although he works only part-time. He has worked at the printing company for the past 35 years. He complains that he cannot hear much of the dialogue on the television. He is accompanied by his wife, who states that her husband cannot hear her at home. He has no history of dizziness, tinnitus, or vertigo. He has had cerumen impactions removed from both ears in the past. Overall, his medical history is quite benign. His only medications are aspirin 81 mg. daily, a multivitamin daily, and occasional ibuprofen for back pain.


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