For this Discussion, you will take on the role of a clinician who is building a health history
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.
ONLY CASE #2!!!!!!
Please note, I also need 2 responses!!! It can be any additional comment or adding additional information about the same topic
Case 1
Case 2
Case 3
Chief Complaint(CC)
A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.
A 45-year-old female presents with a complaint of an itchy red rash on her arms and legs for about two weeks.
A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.”
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.
She has been going on a daily basis to the local YMCA with children for Summer camp.
Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem.
Objective Data
VS
(T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90
(T) 98.3°F; (RR) 18; (HR) 70, regular; (BP) 118/74
(T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb.
General
well-developed, healthy male
healthy-appearing female in no acute distress
well-developed, healthy, 11 years old
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.
EYES: no injection, no increase in lacrimation or purulent drainage;EARS: normalTM: Normal
EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right
Skin
No rashes
CTA AP&L
CTA AP&L
Neck/Throat
no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;trachea midline
mild edema with inflammation located on forearms, upper arms, and chest wall, thighs and knees; primary lesions are a macular papular rash with secondary linear excoriations on forearms and legs
Once you received your case number, answer the following questions:
- 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.
Submission Instructions:
- Your instructor will assign you your case number and you will post on the case number you have been assigned.
- You will reply to the other two case studies (One of each).
- 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.
- You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
- All replies must be constructive and use literature where possible.
CASE STUDY # 2
Answer preview to For this Discussion, you will take on the role of a clinician who is building a health history
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