Read this case and then complete the next part:
Case:
S/ Identifying Information:   (initials, age/DOB, gender, reliability)
J.B., 04/01/1975, female, who is a reliable historian
 
Chief Complaint/RFE:
“My left ear hurts”
Hx Present Illness: (7 Variables but do not list as such)
J.B. is a 49-year-old female, presents with intermittent, “throbbing” pain to her left inner ear and she “can’t stand it anymore”. She rates her pain a # 7 on a pain scale of 0-10. As per J.B., her symptoms started about 2 days ago after being exposed to smoke and cigarettes at a friend’s party. She states her left ear pain lasts a couple of minutes each time she gets it and is taking Tylenol, but “it doesn’t help”. Nothing makes the pain better and lying down makes it worse, as per J.B. The last time J.B. reports taking Tylenol was at 5 pm today. She denies any recent fevers or any associated symptoms such as dizziness or nausea. There is no history of ear infection or trauma to the ears, as per J.B.
CURRENT HEALTH
Medications:  Tylenol 650 mg by mouth every 4-6 hours as needed for pain/fever. No vitamins.
Allergies: No known medication allergies. No food allergies. No environmental or pet allergies.
Last PE & Screenings:  Last physical exam September 17, 2024
Immunization Status:  Annual flu shot on September 18, 2024. Covid booster shot last year September 19, 2023.
LMP & Birth Control (if applicable) Last menstrual period on 10/01/2024
PMH
Illnesses & Trauma:  None reported
Hospitalizations/Surgeries:  Tubal Ligation 2005
OB Hx/Sexual Hx: No complications during pregnancies. Sexually active.
Emotional/Psy Hx: None reported
REVIEW OF SYSTEMS
General: No fevers, no chills, no sweats, no weakness, no loss of appetite.
Nutrition: No loss of appetite.
Skin/Hair/Nails: No rashes, no itching, or hair loss
HEENT: + Left ear pain, no blurred vision, no double vision, no nasal congestion, no epistaxis, no nasal discharge, no sore throat.
Breasts - Deferred
Respiratory: No shortness of breath, no cough, no hemoptysis, no wheezing.
CV/peripheral vascular: No chest pain, no palpitations, no tachycardia, no bradycardia, no syncope, no leg swelling.
GI: No nausea, no vomiting, no diarrhea, no bloating, no blood in stools.  
GU: No difficulty urinating, no dysuria, no hematuria, no urinary urgency, no urinary incontinence.  
MSK: No back pain, no neck pain, no joint pain, no muscle pain, no decreased range of motion. 
Psych: No anxiety, no depression, no thoughts of suicide.  
Neuro: No headaches, no abnormal balance, no numbness, no tingling, no confusion.  
Lymph/Heme/Endocrine: No neck swelling, no neck tenderness, no excessive hunger, no heat intolerance, no cold intolerance. ________________________________                              _______________________ 

O/ Physical Exam: T: 98.6     P: 80     R: 18    BP: 110/62    HT: 61 in    WT: 63.5 kg    BMI: 26.4      
Family Hx:
 
Father: non-living, Hx HTN
Mother: living, HTN
Siblings: living, healthy
MGM: non-living, no Hx
MGF: non-living, no Hx
PGM: non-living, no Hx
PGF: non-living, no Hx

Personal/Social Hx:
J.B. is 49 years old and lives with her husband and two kids under one household. She reports working from home and denies smoking, drinking, use of illicit drugs, and reports no problems at home.
 
 


Now complete this part:

Medical Dx: (2max) 
 Provide pathophysiology related to the diagnosis(s) (1 paragraph each).
Include ICD 10 codes	Rule Outs (only if applicable):  
 	Health Profile: 
 	age/gender/racial  risks:  
Pertinent Positives:(1DX)  
(2 for each diagnosis, Primary and Differential)	 
 	personal/family:  
 	screening needs:  
Pertinent Negatives:  
(2 for each diagnosis, Primary and Differential)	counseling needs:  
 	Immunization/chemo needs:  
Differential DX:(3-5)
(No pathophysiology required)  
Include ICD 10 codes	Alteration in Health Prevention R/T:
 	Screening deficits: 
 	Counseling deficits: 
Nursing Dx:  	Immunization/chemo deficits: