Description
A middle-aged male presents to the office complaining of a two-day history of a left earache. The onset was gradual, but has steadily been increasing. It has been constantly aching since last night, and his hearing seems diminished to him. Today he thinks the left side of his face may even be swollen. He denies upper respiratory infection, known fever, or chills. His patient medical history is positive for Type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient has a known allergy to Amoxicillin that results in pruritus. Medications currently prescribed include Metformin 1,000 milligrams po twice a day, lisinopril 20 milligrams po daily, Aspirin 81 milligrams po daily, and simvastatin 40 milligrams po daily. The physical exam reveals a middle aged male at a weight of 160 pounds, height of 5’8”, temperature of 98.8 degrees Fahrenheit, heart rate of 88, respiratory rate of 18, and blood pressure of 138/76. Further examination reveals the following:
• Face: Faint asymmetry with left periauricular area slightly edematous
• Eyes: sclera clear, conj wnl
• L ear: + tenderness L pinna, + edema, erythema, exudates left external auditory canal, TM not visible
• R ear: no tenderness, R external auditory canal clear without edema, erythema, exudates
• + tenderness L preauricular node, otherwise no lymphadenopathy
• Cardiac: S1 S2 regular. No S3 S4 or murmur.
• Lungs: CTA w/o rales, wheezes, or rhonchi.
Write an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study you selected. Describe the role of the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.
Reference
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.
Sample Solution