Mike, a 62 year-old male, presents to

Mike, a 62 year-old male, presents to the clinic with complaint of right ear pain for 4 days. He recently returned from a snorkeling trip in the Bahamas. His symptoms began with a “deep itching sensation” in the right ear and progressed to pain 7/10. He was unable to sleep well last night as a result. He reports “yellow drainage” on his pillowcase this morning. He applied a warm pack and took 2 extra strength Tylenol for pain relief with poor results. He also tried essential oil in the ear canal without relief. PMH: Hypertension PSH: Carpal Tunnel Repair (R) MEDS: Amlodipine 5mg PO QD; Tylenol 500mg 1-2 PO Q 6 hours PRN SOCIAL HX: Divorced, lives alone. He travels internationally for his job. He does not smoke or use tobacco products. He does drink beer socially on occasion. ROS: General: Denies fever, chills, or fatigue. HEENT: Admits “muffled hearing.” Denies headache, nasal congestion or rhinorrhea, sore throat or oral lesions, excessive tearing or irritation of the eyes. RESP: Denies cough, congestion, shortness of breath, or wheezing. CV: Denies chest pain, palpitations. GI: Denies nausea, vomiting, diarrhea, or abdominal pain. PHYSICAL EXAM: Temp 98.4 P 67 Resp 18 BP 126/76 Oxygen Saturation 99% room air HEENT Exam: Head is normocephalic. Skin is supple and smooth. Conjunctiva are clear, pupils are PERRLA. Nares are patent, pink, and moist without erythema or discharge. Left auricle non-tender. Left ear canal clear, TM is pearly. Right auricle moderately tender. Right canal is erythematous with thick purulent drainage. The Right TM is not visible due to canal swelling. + Right pre-auricular and post-auricular lymphadenopathy. Lips are pink and moist without lesions. Mucus membranes are pink and moist. There is no oropharyngeal erythema. RESP: Vesicular breath sounds throughout. CV: RRR, S1, S2, No gallop, rub, or murmur. What are some of your differential diagnoses in this case? What other information would you seek from this patient? What tests or diagnostic tools would you consider in this case, if any?

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