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 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
