On this Discussion, you will take on the role of a clinician who is building a health history for the following patient:
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.
Vital signs (VS) (T) 99.8F; (RR) 14; (HR) 72; (BP) 138/90
Generalwell-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.
SkinNo rashes
Neck/Throatno neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
trachea midline
Submission Instructions:
Once you received your case number, answer the following:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic examinations do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
Requirements:
at least 500 words ( 2 complete pages of content) formatted and cited in current APA style 7 ed with support from at least 3 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%.
