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.
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
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
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
Heart
Regular rate and rhythm, no murmur, S3, or S4
Regular rate and rhythm, no murmur, S3, or S4
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.
Submission Instructions:
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
Categories