Case Study

CHIEF COMPLAINT: "I have an earache." History of Present Illness:

Johnny B. is a 15-year-old high school student who comes to the office complaining of an earache that has persisted for the last 3 days. His mother says Johnny's forehead felt hot at home, but she did not have a thermometer to check his temperature. He has a decreased appetite and a runny nose with clear to yellow drainage. He has been sneezing but not coughing. Some of his classmates are sick with similar symptoms.

Johnny is healthy. He has never had surgery, and he does not smoke.

What parts of the exam would you like to perform? (Circle the appropriate areas.

General Survey Breasts and Axillae

Vital Signs Female Genitalia

Skin Male Genitalia

Head and Neck Anus, Rectum, and Prostate

Thorax and Lungs Peripheral Vascular/ Extremities

Cardiovascular Musculoskeletal

Abdomen Nervous System

What physical findings are you looking for to help determine the diagnosis?

These are the actual findings on physical examination:

General Survey

Vital Signs



Thorax and Lungs


Alert, interactive, well-nourished adolescent; appears mildly ill

BP 100/60 mm Hg; HR 80 bpm and regular; respiratory rate 24 breaths/min; temperature 100.5°F

No rash

Normocephalic, atraumatic

Pupils equal, round, and reactive to light and accommodation; constrict from 4 mm to 2 mm Disc margins sharp; fundi without hemorrhages or exudates

External ear canals patent, with small amount of cerumen bilaterally

Right tympanic membrane red and bulging; left tympanic membrane dull

Sinuses nontender

Nasal mucosa pink

Oral mucosa pink without enlarged tonsils; pharynx is without exudates

Supple, with spotty anterior cervical adenopathy; no thyromegaly

Thorax symmetric, with good expansion Lungs resonant; breath sounds vesicular

JVP 7 cm above the right atrium; carotid arteries brisk, without bruits

PMI tapping and nondisplaced

Good Sj, S2; no S3 , S4; no murmurs, rubs, or clicks

Based on this information, what is your differential diagnosis?

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