FOR THIS DISCUSSION WE ARE GOING TO USE CASE 2
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Case 1Case 2Case 3Chief Complaint
(CC) A 57-year-old man presents to the office with a complaint of left ear drainage since this morning. A 45-year-old female presents with a complaint of an itchy red rash on her arms and legs for about two weeks. A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.”SubjectivePatient stated he was having pulsating pain on left ear for about 3 days. After the ear drainage the pain has gotten a little better.She has been going on a daily basis to the local YMCA with children for Summer camp.Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem.Objective Data VS(T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90(T) 98.3°F; (RR) 18; (HR) 70, regular; (BP) 118/74(T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb. Generalwell-developed, healthy malehealthy-appearing female in no acute distresswell-developed, healthy, 11 years old HEENTEAR: (R) external ear normal, canal without erythema or exudate, little bit of cerumen noted, TM- pearly grey, intact with light reflex and bony landmarks present; (L) external ear normal, canal with white exudate and crusting, no visualization of tympanic membrane or bony landmarks, no light reflex EYE: bilateral anicteric conjunctiva, (PERRLA), EOM intact. NOSE: nares are patent with no tissue edema. THROAT: no lesions noted, oropharynx moderately erythematous with no postnasal drip.
EYES: no injection, no increase in lacrimation or purulent drainage;
EARS: normal
TM: Normal
EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right SkinNo rashesCTA AP&LCTA AP&LNeck/Throatno neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
trachea midline
mild edema with inflammation located on forearms, upper arms, and chest wall, thighs and knees; primary lesions are a macular papular rash with secondary linear excoriations on forearms and legs
Once you received your case number, answer the following questions:
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.
Expert Solution Preview
Introduction:
As a clinician, building a comprehensive health history is crucial for accurate diagnosis and treatment planning. In this case, a 57-year-old man presents with left ear drainage. To gather more information and reach an accurate diagnosis, additional subjective and objective data need to be obtained, relevant diagnostic exams need to be ordered, and differential diagnoses based on the patient’s presenting symptoms need to be considered.
What other subjective data would you obtain?
In addition to the chief complaint, it is essential to inquire about the patient’s medical and surgical history, including any previous ear infections or ear-related issues. Detailed questioning about the onset, duration, and character of the pain, as well as any associated symptoms like fever or hearing loss, would be important. Further, asking about the presence of any recent upper respiratory tract infections or allergies may provide valuable insights into the underlying cause.
What other objective findings would you look for?
Apart from the initial objective data provided, a thorough examination of the patient’s ear would be conducted, focusing on the left ear with drainage. This examination would involve assessing the appearance and consistency of the drainage, looking for signs of inflammation or infection, and evaluating the integrity of the tympanic membrane. Examination of other cranial nerves and neck lymph nodes for any abnormalities related to the presenting complaint may also be necessary.
What diagnostic exams do you want to order?
Based on the clinical presentation, a few diagnostic exams may be warranted. An otoscope examination of the left ear can help visualize the condition of the external ear canal and tympanic membrane, providing insights into the extent of inflammation or infection. Additionally, ordering a complete blood count with differential can help assess the presence of any systemic infection or signs of inflammation. If indicated, a culture and sensitivity test of the ear drainage may be performed to identify the causative organism and guide appropriate antibiotic therapy.
Name 3 differential diagnoses based on this patient’s presenting symptoms?
1. Acute otitis media: Inflammation and infection of the middle ear, often associated with pain, fever, and ear drainage. It is a common diagnosis in adults and children.
2. Otitis externa: Infection or inflammation of the external ear canal, characterized by pain, tenderness, and often accompanied by ear drainage. More commonly known as swimmer’s ear.
3. Ruptured tympanic membrane: Trauma or infection can cause a perforation in the eardrum, resulting in pain, hearing loss, and ear drainage. It is important to consider this possibility, especially if there is a history of trauma or a sudden change in symptoms.
Give rationales for each differential diagnosis.
1. Acute otitis media: The patient’s symptoms of left ear pain, fever, and ear drainage are consistent with this diagnosis. The absence of visualization of the tympanic membrane and the presence of inflammation in the external ear canal suggest possible middle ear involvement.
2. Otitis externa: The patient’s symptoms of left ear pain, tenderness, and drainage, along with the presence of inflammation, suggest infection or inflammation of the external ear canal. The history of swimming in the YMCA may increase the risk of developing this condition.
3. Ruptured tympanic membrane: If the ear drainage is accompanied by sudden relief of pain and improvement in symptoms, a ruptured tympanic membrane should be considered. Trauma or a severe infection could have caused the rupture, leading to drainage from the ear.
It is important to note that a thorough history, examination, and appropriate diagnostic tests are necessary to confirm the accurate diagnosis and guide treatment decisions.
