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Throat, Respiratory & Cardiovascular Disorders
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 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 spring-time, pollen season. However, in the winter, her allergies are not a problem.
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
Once 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.
Sample Answer
Case 2: 25-year-old Hispanic female, computer programmer, presenting with a 12-day history of a runny nose.
1. What other subjective data would you obtain?
To build a comprehensive health history and narrow down the possibilities, I would gather the following additional subjective data:
A. History of Present Illness (HPI) Elaboration:
- Symptom Onset and Course:
- Did the runny nose start suddenly or gradually?
- Has the discharge color changed over time (e.g., clear initially, then yellow/green)?
- Is the drainage constant or intermittent?
- Has the amount of drainage changed?
- Any specific triggers or alleviating factors (e.g., warm compresses, specific medications)?
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