Differential Diagnosis for 27-year-old Female Post-Assault

The patient presents with a complex set of symptoms 10 days after an assault, including pain behind her left ear, mild auditory changes, left eye pain, nausea, vomiting, and left lower quadrant pain upon vomiting. Given this clinical picture, the differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis

  • Basilar skull fracture: This condition can explain the pain behind the ear, auditory changes (possibly due to damage to the middle ear or inner ear structures), and eye pain (if there's associated trauma to the facial structures). The nausea and vomiting could be related to the head injury or increased intracranial pressure. The pain in the left lower quadrant upon vomiting might be referred pain or indicative of other associated injuries.

• Other Likely Diagnoses

  • Temporomandibular joint (TMJ) disorder: Given the location of the pain behind the ear, TMJ issues could be a consideration, especially if the assault involved a blow to the jaw.
  • Middle ear injury or infection: The auditory changes could suggest an issue with the middle ear, such as a perforated eardrum or an infection secondary to the trauma.
  • Concussion or post-concussive syndrome: The symptoms of nausea, vomiting, and possibly the eye pain could be related to a concussion sustained during the assault.
  • Orbital fracture or injury: The left eye pain could indicate an injury to the orbit, which might require specific evaluation and treatment.

• Do Not Miss Diagnoses

  • Intracranial hemorrhage: Although the patient did not have a CT scan initially, the development of new symptoms such as worsening headache, nausea, vomiting, or changes in mental status could indicate an intracranial hemorrhage, which is a medical emergency.
  • Cervical spine injury: Given the mechanism of injury (assault), it's crucial to consider the possibility of a cervical spine injury, especially if there are any neurological symptoms or signs.
  • Abdominal injury: The left lower quadrant pain upon vomiting could also suggest an intra-abdominal injury, such as a splenic injury, which would require immediate attention.

• Rare Diagnoses

  • Petrous apex syndrome: A rare condition involving the petrous part of the temporal bone, which could explain some of the patient's symptoms, including ear pain and auditory changes.
  • Gradenigo’s syndrome: A rare but serious infection of the petrous apex of the temporal bone, characterized by a triad of symptoms including otitis media, deep facial pain, and abducens nerve palsy.

Recommended Lab Work and Imaging

• CT scans: Of the head, cervical spine, and abdomen to rule out intracranial hemorrhage, cervical spine injuries, and intra-abdominal injuries, respectively.
• MRI: If CT scans are negative but clinical suspicion for certain conditions (like ligamentous injury in the cervical spine) remains high.
• Basic metabolic panel and complete blood count: To assess for any signs of infection, bleeding, or electrolyte imbalances.
• Urinalysis: To check for any signs of urinary tract injury or infection.
• Auditory evaluation: To further assess the nature of the auditory changes.
• Orbital and facial bone CT: If there's a high suspicion of orbital or facial fractures based on clinical examination.

Each of these diagnostic steps is aimed at systematically addressing the potential causes of the patient's symptoms, ensuring that both common and life-threatening conditions are identified and treated appropriately.