NUR 504 Discussion 4
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 instructor will assign you your case number.
Case 1 Case 2 Case 3
Chief 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.
Subjective 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 the previous night. Feels like an ache or a burning sensation at the center of the 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 a 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%
The general patient appears tired; their skin color pale, the patient is diaphoretic and sweaty, height 5′3″; weight 175 lbs No signs of acute distress. A 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.
HEENT 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
Neck/Throat no neck swelling or tenderness with palpation; the 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
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 each differential diagnosis.
Image preview for”for this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.”
APA
737 words