The case study regards a middle-aged male who complains of a two-day left earache history. The onset of the earache was gradual, but has currently increased and the patient reports diminished hearing. The patient’s medical history tests positive for type 2 diabetes mellitus, hypertension, and hyperlipidemia. In summary, the patient’s main concern is earache. However, due to the vagueness of early presenting symptoms, the patient calls for complete examination of head, ears, eyes, nose, and throat (Samuelson & Downey, 2017). In addition, the examination may be performed on lungs, abdomen, lymphatics, and the skin (Samuelson & Downey, 2017). This is because these body parts are infected with similar pathogens, such as streptococcus and Epstein-Bar virus, thus giving similar signs and symptoms.
Primary and Differential Diagnosis for the Patient
Primary Diagnosis
This paper uses the term primary diagnosis to refer to the patient’s conditions that require the most resources and care (Samuelson & Downey, 2017). Based on this case study, the patient presents a case involving earache. Since the patient is an adult male, he is capable of describing his condition orally. Therefore, the primary diagnosis may be based on the patient’s description and examination of the patient’s symptoms using an otoscope instrument (Mann, 2017). In this case, the patient’s hearing is diminished and requires hearing assessment by the use of audiometry or just simple testing using finger rub or whispered voice (Mann, 2017). The patient has signs of middle ear disease, such as swollen face and increased aching, hence needs to undergo tympanic membrane mobility assessment (Mann, 2017). Since the patient denies upper respiratory infection, known fever, and chills, the patient needs nasolaryngoscopy and magnetic resonance imaging on the head and neck with gadolinium contrast in order to rule out tumor (Mann, 2017).
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Differential Diagnosis
The three differential diagnoses for the patient in the case study are: otitis media external, perichondritis, and mastoiditis. The patient’s otitis media external differential diagnosis may include inspection for presence of copious discharge (Mann, 2017). In addition, the pinna may be slightly pulled to check for presence of eliciting pain, while fungal infection may be diagnosed by appearance and culture (Mann, 2017). The patient’s perichondritis diagnosis may entail examination for diffused swelling, redness, and presence of pain on the ear pinna (Mann, 2017). Besides, the diagnosis may be detected by abscess between perichondrium and the cartilage (Mann, 2017). The patient’s mastoiditis diagnosis may be established through examination for presence of swollen ear base, pus coming out of the pinna, and hearing impairment (Mann, 2017).
Based on the case study the patient has a known allergy to Amoxicilin that results in pruritus (Samuelson & Downey, 2017). His left ear is observed to be tender and his left external auditory canal exudates. Besides, he has a tender left preauricular node, but no lymphadenopathy. The patient denies upper respiratory infection, no known fever, or chills. However, the patient’s history tests positive for type 2 diabetes mellitus, hypertension, and hyperlipidemia. The main reason why the differential diagnosis is essential in this case study is to increase the accuracy of the diagnosis. For instance, a culture and antibody studies are considered in order to facilitate differentiation of the similar-appearing processes accruing from the exudation of the external auditory canal (Samuelson & Downey, 2017). In addition, the patient’s condition is increasing and progressive.
Role of Patient History and Physical Examination
The health history of a patient is very important to healthcare professionals because it helps them understand well the medical care to give to a patient (Tidy, 2019). Healthcare providers not only rely on laboratory tests to determine the right prescription for a patient, but rely on information provided by the patient on his or her previous health status. The patient in the case study has a clear previous medical history. He has previously suffered from type 2 diabetes mellitus, hypertension, and hyperlipidemia and is allergic to Amoxicilin that results in pruritus. This previous medical history is important to the healthcare providers because it will guide them in dealing with the earache issue and ensure that the medication which is prescribed to him will not interfere with his health status.
The physical examinations conducted on the patient play a key role in establishing the origin of the earache disorder (Barrell, 2019). The physical examination also helps the healthcare providers to ascertain whether the earache has had any effect on other parts of the patient’s body (Krans & Wu, 2017). For instance, the physical examination showed a slightly swollen face and the left ear. This helped to tell the intensity of the pain caused by the earache. All this information about the patient; from the previous medical history to the physical exams carried on him are important in that they help healthcare providers to clearly diagnose the cause and possible treatment for the earache disorder.
Treatment Options for Ear Disorders
Earache may be approached in three different ways depending on the intensity and the cause of the earache. The patient in the case study has a severe earache and also a past history of type 2 diabetes mellitus, hypertension and hyperlipidemia. The patient has also shown an allergy from amoxillin medicine. Therefore, in administering medication on him, these three illnesses and the allergy must be taken into consideration. The pain caused by the earache can be reduced by administering pain killers on the patient. The pain killers to be administered must not contain any type of amoxillin. The best types of painkillers to administer on this patient are acetaminophen, ibuprofen and aspirin (Mayo Clinic, 2019). These three types of painkillers help to regulate pains in the body and do not have side effects to high blood pressure patients. The pain experienced by this patient can also be regulated by using low heat from a heating pad which works well for adult patients.
The second possible treatment for the patient in the case study is by use of antibiotics. Antibiotics usually deal with illnesses caused by bacterial infections. Since bacterial infections can also cause ear disorders, then the administration of antibiotic is recommended. The patient must be keen to follow all the instructions concerning the antibiotics and ensure that he takes the full dose even if the pain goes away before the dose is over. If a full dose of an antibiotic is not taken, then the disorder is likely to recur and become more resistant to drugs. The third possible way of treatment for the patient is by drainage (Shiel, 2016). Drainage is more appropriate for serious ear complications because the infections cause fluids which remain in the ear and pose possible recurring of the pain in future. Drainage involves creating a small hole in the eardrum and inserting a tube to drain out any form of fluid in the ear. Use of tubes to drain out fluids in the ears have been known to reduce pain, improve hearing of a person and largely cut down the number of infections that a patient may have. Drainage is also recommended for patients who have any form of allergy to other forms of medication.
References
Barrell, A. (2019). What to Expect During a Physical Exam. Retrieved from https://www.medicalnewstoday.com/articles/325488.php
Krans, B., & Wu, B. (2017). Physical Examination. Retrieved from https://www.healthline.com/health/physical-examination
Mann, E. (2017). How to Diagnose and Manage Primary and Secondary Earache and Ear Infections: The Pharmaceutical Journal. Retrieved from https://www.pharmaceutical-journal.com/learning/learning-article/how-to-diagnose-and-manage-primary-and-secondary-earache-and-ear-infections/20202483.article?firstPass=false
Mayo Clinic. (2019). Ear Infection (Middle Ear). Retrieved from https://www.mayoclinic.org/diseases-conditions/ear-infections/diagnosis-treatment/drc-20351622
Samuelson, A.D., & Downey, C.L., (2017). Learn more about Eye-Ear-Nose-Throat Patients with special needs : Treatment Planning in Dentistry (Third Edition). Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/eye-ear-nose-throat
Shiel, W. (2016). Why We Get Ear Infections. Retrieved from https://www.onhealth.com/content/1/ear_infections
Tidy, C. (2019). History Taking. Retrieved from https://patient.info/doctor/history-taking
