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

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.