08 Aug Advance Health Assessment Skin Eye Ear Discussion Questions
Discussion
role of a clinician who is building a health history for the following case study
Case 1
Chief Complaint
(CC) A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.
SubjectivePatient stated he was having pulsating pain on left ear for about 3 days. After the ear drainage the pain has gotten a little better.
Objective Data VS(T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90
Generalwell-developed, healthy male
HEENTEAR: (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.
SkinNo rashes
Neck/Throatno neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
trachea midline
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.
