24 Oct 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 case number is # 2
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 springtime, 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
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
Based on case # 2, 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 each differential diagnosis.
