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
Answer the following questions for your specific case study assigned:
1. What other subjective data would you obtain specific to your case?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient’s presenting symptoms.
5. Give rationales for each differential diagnosis.
· Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 3 academic sources.
Due Wednesday Oct 30 at 11:59pm