A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.
A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.
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 1 | Case 2 | Case 3 | |
| Chief 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.” |
| Subjective | Patient 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. |
| General | well-developed, healthy male | healthy-appearing female in no acute distress | well-developed, healthy, 11 years old |
| HEENT | EAR: (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 |
| Skin | No rashes | CTA AP&L | CTA AP&L |
| Neck/Throat | no 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.
Submission Instructions:
- Your instructor will assign you your case number ( i have case # 3) and you will post on the case number you have been assigned.
- Your initial post should be at least 700 words, formatted and cited in current APA style with support from at least 2 academic sources.
Requirements: 700 words
case study # 3
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