St Thomas University Nursing Discussion
Description
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 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% |
| General | 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. |
| 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; 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 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.
Have a similar assignment? "Place an order for your assignment and have exceptional work written by our team of experts, guaranteeing you A results."
