CASE STUDY #2
CHEIF OF COMPLAIN: 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.
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
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.
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
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