Throat, Respiratory & Cardiovascular Disorders
Case 2 for this one too
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 instructor will assign you your case number.
Case 1Case 2Case 3Chief Complaint
(CC) A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents to the clinic with a cough he has had for the past 2 weeks.A 25-year-old Hispanic female, computer programmer presents to your clinic complaining of a 12-day history of a runny nose A 75-year-old female reports experiencing pain in her chest while walking up steps today.Subjectivedenies chest pain, denies night sweats, admits to having a fever but does not know the temp. 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.Could not sleep previous night. Feels like an ache or a burning sensation at the center of sternum. Denies any arm pain, pain was at a scale of 8 in the AM now it is at a 2. Suffers from History of hypertension, denies heart disease, denies leg swelling up, denies pain feeling worse when taking deep breath. Objective Data VS(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air. (BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room airBP 129/70, (HR) 72 and regular, (RR) 16 unlabored, temperature 98.8°F, oral pulse oximetry is 99% Generalpatient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5?3?; weight 175 lbsNo signs of acute distress. Patient appears mildly fatigued. She is breathing through her mouth. Breathing easily. Voice has a nasal quality to it.obese female, alert, in no acute distress. HEENTEYES: no injection, no increase in lacrimation or purulent drainage;
EARS: normal
TM: Normal
NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Obstructed air passages
Ear canals: normal;
EYES: normal;
NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Nares: Obstructed air passages
Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. Respiratorylung 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 presentCTA AP&LCTA AP&LNeck/Throatno 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
carotids are 2+ without bruits; thyroid is not palpable; no lymphadenopathyHeartRegular rate and rhythm, no murmur, S3, or S4Regular rate and rhythm, no murmur, S3, or S4S1 and S2 normal without murmur, gallop, or rub
Once you received your case number, 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.
