STU Skin Eye and Ear Disorders Case Study – Description
Case study 1: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.Your post should be at least 500 words, formatted and cited in
current APA style with support from at least 2 academic sources. 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
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