nus 504 M3 discussion

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Module 3 Discussion

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icon  Skin, Eye, & Ear Disorders

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

Case 3

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.

Objective Data

 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

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.

 

Submission Instructions:

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

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