What is the diagnosis and treatment plan for a patient presenting with intermittent right eye pressure, ear pain, and sinus pain, with a history of asthma, migraines, and recent travel to Hawaii, currently taking fluoxetine (selective serotonin reuptake inhibitor) and lansoprazole (proton pump inhibitor), and experiencing symptoms such as eye watering, downward gaze pain, and temporal region tenderness?

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Differential Diagnosis

The patient presents with right-sided eye and ear discomfort, intermittent eye pressure, and recent onset of ear and sinus pain. The following differential diagnosis is organized into categories:

  • Single most likely diagnosis:
    • Sinusitis: The patient's symptoms of eye pressure, ear pain, and sinus pain, along with tenderness on palpation of the sinuses and jaw area, are consistent with a diagnosis of sinusitis. The recent history of getting water in the ear during water activities may have contributed to the development of sinusitis.
  • Other Likely diagnoses:
    • Migraine: The patient has a history of migraines, and the current episode of eye pressure and pain could be a migraine variant. However, the presence of ear and sinus pain makes sinusitis a more likely diagnosis.
    • Temporomandibular joint (TMJ) disorder: The patient reports pain in the temporal region and along the gums on the right side, which could be consistent with a TMJ disorder.
    • Eustachian tube dysfunction: The patient's history of getting water in the ear and subsequent ear pain could be related to Eustachian tube dysfunction.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):
    • Temporal arteritis: Although the patient does not have severe tenderness in the temporal region, temporal arteritis is a potentially deadly condition that can cause eye pain, headache, and jaw claudication. It is essential to consider this diagnosis, especially in patients over 50 years old.
    • Orbital cellulitis: The patient's symptoms of eye pain, watering, and tenderness could be consistent with orbital cellulitis, a serious infection that requires prompt treatment.
    • Cavernous sinus thrombosis: This rare but potentially life-threatening condition can cause eye pain, headache, and cranial nerve deficits.
  • Rare diagnoses:
    • Trigeminal neuralgia: The patient's symptoms of eye and facial pain could be consistent with trigeminal neuralgia, a rare condition characterized by sudden, severe facial pain.
    • Sphenoid sinusitis: The patient's symptoms of eye and ear pain, along with sinus pain, could be consistent with sphenoid sinusitis, a rare condition that can cause severe headache and facial pain.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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