NUR 504 Saint Thomas Treatment Processes and Clinical Interventions Case Study
NUR 504 Saint Thomas Treatment Processes and Clinical Interventions Case Study
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
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
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.
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Case Study of NUR 504 Saint Thomas Treatment Processes and Clinical Interventions
Case Study of NUR 504 Saint Thomas Treatment Processes and Clinical Interventions
The Main Complaint
(CC)
A 25-year-old Hispanic female computer programmer arrives at your clinic with a 12-day history of runny nose.
Subjective
Her symptoms began about 12 days ago, according to her. She has allergies, and she has a runny nose during pollen season in the spring. Her allergies, on the other hand, are not a problem in the winter.
Data that is objective
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
