Case 1
Chief Complaint
(CC)
A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.
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.
VS
(T) 99.8?F; (RR) 14; (HR) 72; (BP) 138/90
General
well-developed, healthy male
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.
Skin
No rashes
Neck/Throat
no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline
Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic examination do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
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