Module 4 Discussion
Class: Nur 504 Advanced Health Assessment
Throat, Respiratory & Cardiovascular Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
Your case number is # 2
Case 2 | |
Chief Complaint | A 25-year-old Hispanic female, computer programmer presents to your clinic complaining of a 12-day history of a runny nose |
Subjective | States that her symptoms began about 12 days ago. She suffers from allergies; she gets a runny nose during the springtime, pollen season. However, in the winter, her allergies are not a problem. |
Objective Data | |
VS | (BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air |
General | No signs of acute distress. Patient appears mildly fatigued. She is breathing through her mouth. Breathing easily. Voice has a nasal quality to it. |
HEENT | Ear canals: normal; |
Respiratory | CTA AP&L |
Neck/Throat | Posterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, no |
Heart | Regular rate and rhythm, no murmur, S3, or S4 |
Based on case # 2, answer the following questions:
1.
What other subjective data would you obtain?
2.
What other objective findings would you look for?
3.
What diagnostic exams do you want to order?
4.
Name 3 differential diagnoses based on this patient presenting symptoms.
5.
Give rationales for each differential diagnosis.
