Posted: March 5th, 2022

NUR 504 Saint Thomas Treatment Processes and Clinical Interventions Case Study

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.

——–

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

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