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 2


Case 1 Case 2 Case 3

Chief Compl aint (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.

Subje ctive

denies 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 air

BP 129/70, (HR) 72 and regular, (RR) 16 unlabored, temperature 98.8°F, oral pulse oximetry is 99%

Gener al

patient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs

No 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.

HEEN T

EYES: 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.

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 CTA AP&L


 Once you received your case number, 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.

Submission Instructions:

• Your instructor will assign you your case number and you will post on the case number you have been assigned.

• You will reply to the other two case studies (One of each). • Your initial post should be at least 500 words, formatted and

cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)

• All replies must be constructive and use literature where possible

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

carotids are 2+ without bruits; thyroid is not palpable; no lymphadenopathy

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

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

S1 and S2 normal without murmur, gallop, or rub

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