Skin, Eye, and Ear Disorders Case 3
University:
St. Thomas University
Skin, Eye, and Ear Disorders Case 3
Paper Instructions
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 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 normal
TM 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’
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Sample Answer
Subjective Data
The assigned case study is that of an 11-year-old female patient who complains of red left eye and edematous eyelids. She also complains of sand in my left eye. The additional subjective information that should be obtained from the patient includesany recent infection, worsening or relieving factors, and any remedies they have used to manage the problem. Exposure to viral and bacterial infections may contribute to problems such as conjunctivitis. Information about worsening or relieving factors for the pain will guide the development of an appropriate plan. Information about remedies will aid prescribe appropriate medications and eliminate the risk of drug interactions.
Objective Findings
The additional objective findings for the client are changes in vision, pupil changes and response to light, and assessing potentials of eye trauma or presence of foreign bodies.
Diagnostic Exams
One of the diagnostic examinations is slit lamp examination to determine any changes such as corneal opacity. The other test is visual acuity test to determine changes in vision. The last one is eye culture to determine if the cause is due to a bacterial or viral infection(Azari&Arabi, 2020).
Differential Diagnoses
The first differential diagnosis is bacterial conjunctivitis. Bacterial infections such as Hemophilus influenza and Staphylococcus aureus may cause bacterial conjunctivitis. Bacterial conjunctivitis has symptoms such as red eye, discharge, tearing, and discomfort. The other differential is viral conjunctivitis. Viruses such as adenovirus, rhinovirus, and piconavirus may cause viral conjunctivitis.
Viral conjunctivitis has symptoms such as red eye, itchiness, gritty feeling, and tearing. The last differential diagnosis is eye trauma. Eye trauma can result in red eyes, irritation, and changes in vision(Azari&Arabi, 2020; Marinos et al., 2019; Yeu & Hauswirth, 2020). Therefore, additional investigations should be performed to rule out these causes.
References
- Azari, A. A., &Arabi, A. (2020). Conjunctivitis A Systematic Review. Journal of Ophthalmic & Vision Research, 15(3), 372–395. https //doi.org/10.18502/jovr.v15i3.7456
- Marinos, E., Cabrera-Aguas, M., & Watson, S. L. (2019). Viral conjunctivitis A retrospective study in an Australian hospital. Contact Lens and Anterior Eye, 42(6), 679–684. https //doi.org/10.1016/j.clae.2019.07.001
- Yeu, E., & Hauswirth, S. (2020). A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis Implications for Treatment and Management. Clinical Ophthalmology, 14, 805–813. https //doi.org/10.2147/OPTH.S236571
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