CASE STUDY_EAR
History Data:
Chief concern: “I have been having nasal congestion and Right ear itchy with tenderness for the past two weeks”
HPI: This is 64 years old African American male who has history of HLD, severe rheumatoid arthritis s/p multiple surgeries and s/p right knee replacement in October 2023, Pseudo-GOUT and Anemia secondary to chronic disease. He stated that he has nasal congestion and right ear itchy with tenderness for the past two weeks. he has also had swelling of his both knees and feet for the past two weeks, states that his right knee is more swollen than the left. He stated that he visited surgeon and was diagnosed to be pseudo-gout and prescribed Colchicine 1.2 mg per day and also had arthrocentesis. He denies feeling tired , fever, cough, SOB, night sweats, pain, denies dizziness
Pertinent PMH: This is 64 years old African American male who present to the office on 06/05/2024, with complaint of increased nasal congestion and Right ear itchy with tenderness for the past two weeks. he denies any recent travel or any sick contact at home or at work. Pt has a PMH of pseudo-gout currently taking Colchicine 1.2 mg per day, HLD on Crestor 5 mg tablet , RA, Rt knee replacement, left wrist fusion, right open reduction fixation of the right thumb, s/p colostomy and abdominal surgery post gun shot. Anemia secondary to chronic disease on Cyanocobalamin injections, endorses that he drinks alcohol occasionally, denies tobacco use or recreational drugs. Patient has NKDA, has seasonal allergies. no significant family medical hx, both parents passed from old age. Patient is not married but has one daughter who lives in Atlanta Geogia no health problems were reported His last BM was this morning. Patient is not up to date on his vaccines, refused yearly flu shot, received two Covid vaccines of Pfizer, refused the booster
Currently medications
· vit d2 1.25 mg (50,000 unit), take 1 capsule (50,000 unit) by oral route once weekly
· cyanocobalamin 1,000 mcg/ml, inject 1 milliliter (1,000 mcg) by intramuscular monthly
· folic acid 1 mg tablet, take 1 tablet (1 mg) by oral route once daily
· protonix dr 40 mg tablet, take 1 tablet (40 mg) by oral route once
· Crestor 5 mg tablet, take 1 tablet (5 mg)
· multi-day plus minerals tablet, one once a day
· azelastine 0.1% (137 mcg) spry, spray 2 sprays in each nostril by intranasal route 2 times per day
· singulair 10 mg tablet, take 1 tablet (10 mg) by oral route once daily in the evening
· neomycin-polymyxin-hc ear susp, instill 2 drops into affected ear(s) by otic route 3 times per day left ear and right ear 3 days;
· Claritin 10 mg liquid-gel cap, Flonase allergy rlf 50 mcg spry, inhale 2 sprays (100 mcg)
INSTRUCTIONS
1. Three Differential Diagnosis: ( first one must be the primary diagnosis)
2. Pathophysiology for Diagnosis (each diagnosis) with etiology
3. Pertinence of Research Article (for primary diagnosis)
4. Plan of Care: Testing/Studies:
5. Pharmacological:
6. NONPHARMACOLOGIC METHODS SHOULD BE DISCUSSED ALSO
7. Patient Education:
8. Follow up:
Ciprofloxacin (Cipro) 500 mg tablet orally every 12hrs for seven days
Acetaminophen 650 mg tablet orally every 4-6 hours as needed.
Ondansetron (Zofran) 8 mg tablet orally every 12 hours as needed for seven days.
APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2019-2024 only. (Within the last 5 years)
Please do not solely use a website as your scholarly reference, fine to use as supplement, but a journal article should be referenced or a text.
Please use reliable medical references such as Current Medical Diagnosis and Treatment book, or UpToDate. Do NOT use WebMD, Wikipedia etc. as these are not advance practice references.
APA format (if using outside sources).