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 suggestive of a possible early sinus infection?

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Differential Diagnosis

  • Single most likely diagnosis:
    • Sinusitis: The patient's symptoms of persistent eye and ear discomfort, sinus pain, and slight congestion in the right nostril are consistent with a diagnosis of sinusitis. The recent history of getting water in the ear during water activities and the onset of symptoms after returning from vacation also support this diagnosis.
  • 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 persistence of symptoms and the presence of ear and sinus pain make sinusitis a more likely diagnosis.
    • Temporomandibular joint (TMJ) disorder: The patient's report of pain in the temporal region and along the gums on the right side could be consistent with a TMJ disorder. However, the absence of specific gum or teeth pain and the presence of other symptoms make this diagnosis less likely.
    • Otitis externa: The patient's history of getting water in the ear and the onset of ear pain could be consistent with otitis externa. However, the absence of redness or bulging of the ear and the presence of other symptoms make this diagnosis less likely.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):
    • Temporal arteritis: Although the patient is relatively young, temporal arteritis is a potentially deadly condition that can cause headache, jaw pain, and eye symptoms. The patient's report of pain in the temporal region and the presence of eye symptoms make this diagnosis a "do not miss" condition.
    • Orbital cellulitis: This is a serious infection of the tissues surrounding the eye that can cause eye pain, swelling, and vision changes. Although the patient does not have significant vision changes, the presence of eye pain and swelling make this diagnosis a "do not miss" condition.
    • Cavernous sinus thrombosis: This is a rare but potentially deadly condition that can cause headache, eye pain, and vision changes. Although the patient does not have significant vision changes, the presence of eye pain and swelling make this diagnosis a "do not miss" condition.
  • Rare diagnoses:
    • Trigeminal neuralgia: This is a rare condition that can cause severe facial pain, including eye and ear pain. Although the patient's symptoms are consistent with this diagnosis, it is relatively rare and would require further evaluation to confirm.
    • Sphenoid sinusitis: This is a rare condition that can cause headache, eye pain, and ear pain. Although the patient's symptoms are consistent with this diagnosis, it is relatively rare and would require further evaluation to confirm.

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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