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.

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

CTA AP&L

Neck/Throat

Posterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, no cobblestoning

Heart

Regular rate and rhythm, no murmur, S3, or S4

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 your each differential diagnosis.

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