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CC: Headache and left ear pain for three days
HPI: The patient is a 29 yo male with PMHx significant for poorly controlled Diabetes Type II and asthma as well as mastoiditis 1 year ago treated with surgical intervention by ENT. He presents to the ED with complaint of a moderate headache and left ear pain x 3days. He also complained of viral URI symptoms, left facial pain, neck pain, and some dizziness, photophobia, and 1 episode of vomiting today. He denied fever at home. Pt lives at home with girlfriend and her two 8 month old twins. The twins recently, within the past two weeks, suffered from otitis media, successfully treated with oral antibiotics.
PE: Vital Signs: P- 109, BP- 165/99, Temp(oral) 100.6. O2 sat 98% RA.
General Appearance: Pt in moderate distress.
HEENT: PERRLA, EOMI, Conjunctiva non-injected. Left ear canal purulent with bulging TM. Right ear canal clear and TM crisp. No mastoid tenderness or induration. Nares clear of mucous. Throat without exudates or erythema; no petechia.
NECK: painful to passive and active extension/flexion. Kernigs and Brudzinski's negative (for what that's worth)
LUNGS: CTA B/L. No wheezes/ rhonchi/ rales.
HEART: RRR. No murmurs/ rubs.
ABDOMEN: Benign, +BS, Nontender/ nondistended.
SKIN: No rashes.
Extremities: No edema.
NEURO: Ax Ox 3. No focal deficits.
While in the ED, the patient complains of worsening left sided headache despite the analgesia and hydration and vomits two more times.
ED COURSE: Pt had IV line in place. An unenhanced CT of the brain was done (see images below). Pt received morphine 2 mg for pain. He also received 2 L NS.
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What is the differential diagnosis at this point?
Does the fact that the patient has a left otitis media obviate the need for further work up?
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