ST Thomas University 3 Female CP Case Study
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 1Case 2Case 3Chief 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 noseA 75-year-old female reports experiencing pain in her chest while walking up steps today.Subjectivedenies 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 airBP 129/70, (HR) 72 and regular, (RR) 16 unlabored, temperature 98.8°F, oral pulse oximetry is 99% Generalpatient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5′3″; weight 175 lbsNo 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. HEENTEYES: no injection, no increase in lacrimation or purulent drainage;EARS: normalTM: NormalNOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Obstructed air passagesEar canals: normal;EYES: normal;NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Nares: Obstructed air passagesAtraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. Respiratorylung 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 presentCTA AP&LCTA AP&LNeck/Throatno neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;trachea midlinePosterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, nocobblestoningcarotids are 2+ without bruits; thyroid is not palpable; no lymphadenopathyHeartRegular rate and rhythm, no murmur, S3, or S4Regular rate and rhythm, no murmur, S3, or S4S1 and S2 normal without murmur, gallop, or rubOnce you received your case number, 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.Submission Instructions:Your instructor will assign you your case number and you will post on the case number you have been assigned.You will reply to the other two case studies (One of each).Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.) All replies must be constructive and use literature where possible.Grading Rubric Your assignment will be graded according to the grading rubric.Discussion RubricCriteriaRatingsPointsIdentification of Main Issues, Problems, and Concepts5 pointsDistinguishedIdentify and demonstrate a sophisticated understanding of the issues, problems, and concepts.4 pointsExcellentIdentifies and demonstrates an accomplished understanding of most of the issues, problems, and concepts.2 pointsFairIdentifies and demonstrates an acceptable understanding of most of the issues, problems, and concepts.1 pointPoorIdentifies and demonstrates an unacceptable understanding of most issues, problems, and concepts.5 pointsUse of Citations, Writing Mechanics and APA Formatting Guidelines3 pointsDistinguishedEffectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors.2 pointsExcellentEffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling errors.1 pointFairIneffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.0 pointPoorIneffectively uses the literature and other resources to inform their work. Unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention.3 pointsResponse to Posts of Peers2 pointsDistinguishedThe student constructively responded to two other posts and either extended, expanded, or provided a rebuttal to each.1 pointFairThe student constructively responded to one other post and either extended, expanded, or provided a rebuttal.0 pointPoorThe student provided no response to a peer's post. 2 points