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:
1. What other subjective data would you obtain?
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 presenting symptoms?
5. Give rationales for your each differential diagnosis.