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Case Study 2

 

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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

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·      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.

 

Please respond to the following to this discussion post regarding Case study 2.You can agree or add on the differential diagnosis and post other suggestion on treatment options based on your diagnosis of the case study.

 

 

(Meriam’s Post)

 

   As an advanced nurse practitioner, it is important to listen to the patient tell the story of the history of their present illness.  The information that is provided by the patient in conjunction with the findings from the physical examination gives the nurse practitioner a comprehensive understanding of the patient’s diagnosis.  In this case, upon a thorough investigation, it is determined that the patient has a case of an acute otitis externa to the left ear.  Acute otitis externa (AOE) is described by Balch, Heal, Cervin, and Gunnarsson (2019) as an inflammation of the outer ear and ear canal is also known as “swimmers ear” that can be attributed toPseduomonas spp., Staphylococcus aureusand various fungi.

            The information that the patient provided that justified this diagnosis was the history of left earache for 2 days, diminished hearing, denied having an upper respiratory infection, fever, or chills.  The patient’s medical history also included being a Type II diabetic which according to Abdullahi and Aliyu (2016), diabetes mellitus is considered a risk factor for otitis externa. Findings from the physical exam that supported the diagnosis of acute otitis externa were faint asymmetry to face with the left preauricular slight edematous, tenderness to left pinna, exudate to left external auditory canal and the tympanic membrane was not visible. Ansley, Mair, Namini, Lu, and LeBel (2019) mention that the signs and symptoms include otalgia, tenderness of the tragus and pinna, diffuse ear canal edema, conductive hearing loss, erythema, and otorrhea which correlates with the findings in the physical exam of this patient.

            Treatment wise, it is also important to know if the patient has any allergies, which in this case he is allergic to Amoxicillin. According to Wiegand, Berner, Schneider, Lundershausen, and Dietz (2019) treatment of uncomplicated acute otitis externa consists of cleaning the ear canal, topical antiseptic and antimicrobial treatment, adequate analgesia and include an oral antibiotic treatment if it has spread beyond the ear canal in a poorly controlled diabetic. Wiegand, Berner, Schneider, Lundershausen, and Dietz (2019) also suggest that oral antibiotic should be effective against bothPseduomonas aeruginosaandStaphylococcus aureussuch as quinolones, but optimally should be according to the findings of the bacterial culture and sensitivity testing.

            Differential diagnosis includes acute otitis media, malignant otitis externa, and referred dental pain. Acute otitis media can easily be confused with acute otitis externa, which is why it is important to be attentive to the details when the patient is providing subjective information. Acute otitis externa can also be confused for malignant otitis externa, especially in this case because the patient is diabetic which according toYang et al. (2020) coincide and can also result from aPseduomonas aeruginosaandStaphylococcus aureusinfection.  The third differential diagnosis is referred dental pain.  A dental infection can lead to edema and pain to the surrounding area that includes the pinna and tragus.

 

 

Resources: You may use the following resources on top of other resources you may use for references.

 

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice(5th ed.). St. Louis, MO: Elsevier.

 

·      Part 6, “Evaluation and Management of Eye Disorders” (pp.326-358) 

This part covers eye examinations and explores the pathophysiology, clinical presentation, physical examination, diagnostics, and management of eye disorders, including cataracts, conjunctivitis, and dry eye syndrome.

 

·      Part 7, “Evaluation and Management of Ear Disorders” (pp. 359-377) 

This part reviews factors contributing to the diagnosis and treatment of ear disorders, such as symptoms, patient history, physical exams, and indications for referral or hospitalization. It also covers lifespan considerations, complications, and methods for educating patients and families about ear disorders.

 

·      Part 8, “Evaluation and Management of Nose Disorders” (pp.378-397)

This part explores the development of differential diagnoses for nose disorders. Nose disorders such as chronic nasal congestion and discharge, nasal trauma, rhinitis, and sinusitis are examined, as well as related complications, indications for referral or hospitalization, and health promotion strategies.

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