Uncategorized
Case Study 2Case Study 2
Learning Goal: I’m working on a nursing case study and need an explanation and answer to help me learn.
| Case 2 | |||
| Chief Complaint (CC) |
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 spring-time, 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; EYES: normal; NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Nares: Obstructed air passages |
||
| Respiratory | lung crackles in LLL, no wheezes or rhonchi noted; does not clear with coughing; dullness to percussion over the LLL; shallow respirations and is 30, accessory muscles use not present | CTA AP&L | |
| Neck/Throat | no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline |
Posterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, no cobblestoning |
|
| Heart | Regular rate and rhythm, no murmur, S3, or S4 | Regular rate and rhythm, no murmur, S3, or S4 | |
answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
Submission Instructions:
- Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.