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Asked by MateOxideStarling26
Chief Complaint:Â presenting with pain in right ear.
History of Present Illness: has had right ear pain for three days. Pain is getting progressively worse. Notices it more when laying down. Denies loss of hearing or tinnitus. States her allergies have been bad with postnasal drainage and sneezing for the last couple weeks. Thinks she may have had a cold but is not sure with her allergies. Denies fever or chills.
Past Medical History: Seasonal allergies – “worse in springtime”, otherwise unremarkable.
Family History: Non-contributory
Social History: Non/never-smoker; Drinks socially with friends on the weekend. Full-time nursing student with part-time waitressing job.
Current Medications: Claritin when allergies she remembers it for her allergies – 3-4 times a week.
Allergies: Other than grass and pollen had no other allergies.
Vital signs: T: 99.6Â Â Â P:78Â Â R: 12Â Â Â BP: 110/76Â O2Sat: 96%Â Ht: 5’2″Â Â Wt: 132 lbs
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Pertinent physical exam findings:
HEENT: PERRLA; no eye drainage noted; conjunctiva pink; no lymphadenopathy in head, neck, or axilla; nasal mucous membranes moist with watery drainage noted; no ocular discharge; pinna normal with no external ear tenderness; otoscopic exam findings: Right tympanic membrane erythematous & bulging with fluid noted behind the membrane. No redness or drainage noted in throat.
Respiratory: lungs clear bilaterally
Point of Care Testing Completed (on-site):Â none
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Complete the following questions and post to Discussion Board on Blackboard Module 5:
What are the patient’s most significant key presenting features?
What are your top three (3) Differential Diagnoses and why?
What additional diagnostic or imaging testing should be ordered and why?
What is the patient’s most likely diagnosis?
How is the patient’s condition typically treated?
SCIENCE
HEALTH SCIENCE
NURSING
NURSING 8080
