Take on the role of a clinician who is building a health history for one of the following cases.
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.
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
- 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.
As a clinician building a health history for the presented case, it is essential to gather comprehensive data to form an accurate diagnosis. Below are the responses to each of the requested points:
1. Additional Subjective Data to Obtain
To gain a more thorough understanding of the patient's condition, I would ask the following questions:
- Onset and Duration of Symptoms: When did you first notice the pulsating pain? Has it worsened or improved since it started?
- Nature of Ear Drainage: Can you describe the drainage? (e.g., color, consistency, odor)
- Associated Symptoms: Have you experienced any other symptoms such as fever, chills, hearing loss, or tinnitus?
- Previous Episodes: Have you had similar ear issues in the past? If so, how were they treated?
- Recent Illnesses: Have you had any recent upper respiratory infections, allergies, or sinus issues?
- Medications: Are you currently taking any medications or have you taken any recently?
- Allergies: Do you have any known allergies, particularly to medications?
- Lifestyle Factors: Have you been exposed to water (swimming, bathing), or have you had any recent travel?
2. Additional Objective Findings to Look For
In addition to the initial examination, I would look for the following objective findings:
- Hearing Assessment: Conduct a hearing test (e.g., Rinne and Weber tests) to evaluate for conductive or sensorineural hearing loss.
- Palpation of the Auricle and Mastoid: Check for tenderness or swelling around the auricle and mastoid process, which could indicate mastoiditis or external otitis.
- Neurological Examination: Assess for any neurological deficits or signs of cranial nerve involvement due to possible complications.
- Lymphadenopathy: Check for swollen lymph nodes in the head and neck area that may indicate infection.
3. Diagnostic Exams to Order
Based on the findings from the history and physical examination, I would consider ordering the following diagnostic exams:
- Ear Culture: To identify any bacterial or fungal pathogens present in the ear drainage.
- Complete Blood Count (CBC): To check for signs of infection, such as leukocytosis.
- Audiometry: If hearing loss is suspected, a formal hearing test can assess the extent and type of hearing impairment.
- Timpanic Membrane (TM) Examination: If possible, consider tympanometry or otoscopy with a pneumatic attachment to assess TM mobility.
4. Differential Diagnoses
Based on the patient's symptoms, three differential diagnoses include:
1. Acute Otitis Media (AOM):
- Rationale: The patient presents with ear pain and drainage, which can be indicative of AOM. The erythematous or bulging tympanic membrane is not visible in this case but could be present if examined.
2. Chronic Suppurative Otitis Media (CSOM):
- Rationale: The presence of white exudate and crusting in the left ear suggests a chronic infection that might lead to ongoing drainage and pain. CSOM often leads to perforation of the tympanic membrane.
3. External Otitis (Swimmer's Ear):
- Rationale: The drainage and crusting noted in the external canal could suggest external otitis, especially if there has been recent water exposure. Symptoms often include pain exacerbated by pulling on the auricle.
Conclusion
This structured approach ensures that all pertinent information is gathered to inform clinical decisions accurately. By exploring further subjective data, additional objective findings, necessary diagnostic exams, and developing a list of differential diagnoses with rationales, we can provide appropriate management for this patient’s condition.