FOR THIS DISCUSSION WE ARE GOING TO USE CASE 2
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 1Case 2Case 3Chief 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.”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.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. Generalwell-developed, healthy malehealthy-appearing female in no acute distresswell-developed, healthy, 11 years old 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.
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 SkinNo rashesCTA AP&LCTA AP&LNeck/Throatno 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
Once you received your case number, 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.
