A73 yo wm with a history of hypertension (htn) and type 2 diabetes mellitus (dm) presents to your office with excruciating left ear pain for the past 3 days. he also noticed that today his speech seems a bit slurred. his wife says that the left side of his face looks "droopy." he has had so much pain and swelling that he hasn't been able to put his hearing aid in for several days. he cleans his ears daily with cotton swabs prior to putting in his hearing aid. he denies having a fever, but says that his blood sugars have been higher than usual for the past 2 days. pmhx: the patient had "swimmer's ear" in the past, which responded to treatment with ear drops. he denies any ear problems in the last several years. physical exam (pe): vss afebrile wd wn wm in nad he is in obvious pain and has a prominent left-sided facial droop. ear = left ear is diffusely swollen, and is tender on the pinna, the entire periauricular area, and the mastoid. there is purulent drainage from the ear canal. you are unable to insert a speculum into the canal because of the swelling and pain. neuro = evidence of facial nerve palsy on the left side. lab = blood tests show an elevated wbc count and a markedly elevated erythrocyte sedimentation rate (esr). definitions: palsy: complete paralysis (neurology). pinna = the outer projecting portion of the ear. periauricular: around the external ear. erythrocyte sedimentation rate (esr): a measure of the time it takes for red blood cells to settle (a nonspecific measure of inflammation) ecthyma gangrenosum: pustular skin lesions that later become necrotic ulcers and can lead to gangrene. discussion questions 1. what is your diagnosis? 2. what organism is the most likely etiology of this infection? 3. which two toxins contribute to most of the systemic toxicity of this organism? 4. what is meant by nad in the physical exam section?