Module 4 Discussion Class: Nur 504 Advanced Health Assessment


Module 4 Discussion


Class: Nur 504 Advanced Health Assessment


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.

 

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Geriatric Care Plan Concept Map Risk Factors for Nursing Diagnosis (3) 1.

Geriatric Care Plan Concept Map Risk Factors for Nursing Diagnosis (3) 1. Dementia 2. Lung disease 3. Recent viral illness Complications to Report (3) 1. Weight loss 2. Falls 3. Dizziness Challenges to Implementing Care Plan (3) 1. Resident’s mental capacity 2. Time 3. Etc. Things I Learned/Surprised Me After

738.2.1 : Foundations of Inquiry The learner differentiates between quality improvement processes, evidence-based practice, and research.

738.2.1 : Foundations of Inquiry The learner differentiates between quality improvement processes, evidence-based practice, and research. 738.2.2 :  Literature Review and Analysis The learner demonstrates knowledge of the process and outcomes of conducting a literature review. 738.2.3 :  Ethics and Research The learner demonstrates an understanding of the ethics of nursing research particularly human