When entering examination rooms, advanced practice nurses often immediately begin assessing patients by looking for external abnormalities such as skin irritations or cloudy eyes. By making these simple observations, they can determine how to proceed with their patient evaluations. During the patient evaluation, advanced practice nurses will use initial observations to guide them in acquiring the necessary medical history, performing additional assessments, and ordering the appropriate diagnostics. The information obtained during this evaluation process will help in the development of a differential diagnosis. Once a diagnosis is made, the advanced practice nurse can consider potential treatment options and work with the patient to develop a plan of care. For this Discussion, consider the following four case studies of patients presenting with skin, eye, ear, and throat disorders.

Case Study 1:

A 46-year-old male presents to the office complaining of a pruritic skin rash that has been present for a few weeks. He initially noted the rash on his chest, but it then spread to his back and arms. He notes that it does not seem to be on his legs. He recently came home from a trip to Florida, but denies fever, chills, new soaps or detergents, other travel, or known insect bites. He takes occasional ibuprofen for knee pain, but denies taking other medications or having other health problems. He has no known drug allergies. The physical examination reveals a male with a deep tan and notable scattered 1–1.5-centimeter, flat, circular, light-colored patches on his chest, back, and upper extremities.

Case Study 2:

An 86-year-old widowed female is brought to the office by her daughter-in-law. The patient complains of constant tearing and an itchy, burning sensation in both eyes. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The patient complains that her eyes are dry. She thinks the problem must be caused by one of her medications. Her patient medical history is positive for hypertension, atrial fibrillation, and heart failure. She has an allergy to erythromycin that causes rash and elevated liver enzymes. Medications currently prescribed include Furosemide 40 milligrams po twice a day, diltiazem 240 milligrams po daily, lisinopril 20 milligrams po daily, and warfarin 3 milligrams po daily. The physical examination reveals a frail older female with some facial dryness and slight scaling. Her visual acuity is 20/60 OU, 20/40 OD, 20/60 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes. Sclera are injected, conjunctiva are pale, and pupils are equal and reactive to light and accommodation.

Case Study 3:

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
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.
Case Study 4:
A middle-aged female presents to the office complaining of strep throat. She states she suddenly developed a sore throat yesterday afternoon, and it has gotten worse since then. During the night she felt like she was chilled and feverish. She denies known recent contact with anyone else who had strep throat, but states she has had strep before and it feels like she has strep now. She takes no medications, but is allergic to penicillin. The physical examination reveals a slender female lying on the examination table. She has a temperature of 101 degrees Fahrenheit, heart rate of 112, respiratory rate of 22, and blood pressure of 96/64. The head, eyes, ears, nose, and throat evaluation is positive for bilateral tonsillar swelling without exudates. Her neck is supple with bilateral, tender, enlarged anterior cervical nodes.

To prepare:

Review this week’s media presentations and Parts 5–8 of the Buttaro et al. text.
Select one of the four case studies provided.

Reflect on the provided patient information including history and physical exams.

Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis.

Reflect on potential treatment options based on your diagnosis.

Discuss or provide an explanation of the differential diagnosis for the patient in the case study that you selected.

Describe the role the patient history and physical exam played in the diagnosis.

Then, suggest potential treatment options based on your patient diagnosis.

RESOURCES:

Readings
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.
Part 5, “Evaluation and Management of Skin Disorders” (pp. 227–312)

This part explores the pathophysiology, clinical presentation, and management of various skin disorders, including dermatitis, dry skin, fungal infections, and herpes. It also examines the pathophysiology, clinical presentation, physical examination, diagnostics, and management of wound healing.
Part 6, “Evaluation and Management of Eye Disorders” (pp. 313–344)

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. 345–364)

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. 365–384)

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.
Media
Laureate Education, Inc. (Executive Producer). (2013a). Case studies: Ear disorder. Baltimore, MD: Author.

Note: The approximate length of this media piece is 11 minutes.

This media presentation features an evaluation of a patient presenting with an ear disorder.
Laureate Education, Inc. (Executive Producer). (2013e). Case study: Throat disorder. Baltimore, MD: Author.

Note: The approximate length of this media piece is 11 minutes.

This media presentation features an evaluation of a patient presenting with a throat disorder.