case study 3 – Female CP

I’m trying to study for my Nursing course and I need some help to understand this question.

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

Once you received your case number, 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 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.

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Grading Rubric


Your assignment will be graded according to the grading rubric.

Discussion Rubric
Criteria Ratings Points

Identification of Main Issues, Problems, and Concepts

5 points
Distinguished

Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts.

4 points
Excellent

Identifies and demonstrates an accomplished understanding of most of the issues, problems, and concepts.

2 points
Fair

Identifies and demonstrates an acceptable understanding of most of the issues, problems, and concepts.

1 point
Poor

Identifies and demonstrates an unacceptable understanding of most issues, problems, and concepts.

5 points

Use of Citations, Writing Mechanics and APA Formatting Guidelines

3 points
Distinguished

Effectively 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 points
Excellent

Effectively 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 point
Fair

Ineffectively 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 point
Poor

Ineffectively 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 points
Response to Posts of Peers

2 points
Distinguished

The student constructively responded to two other posts and either extended, expanded, or provided a rebuttal to each.

1 point
Fair

The student constructively responded to one other post and either extended, expanded, or provided a rebuttal.

0 point
Poor

The student provided no response to a peer’s post.

2 points

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