Skin, Eye, & Ear Disorders
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 | |
| 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 |
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.
Skin, Eye, & Ear Disorders
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 | |
| 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 |
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.
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