Throat, Respiratory, & Cardiovascular Disorders

 

Throat, Respiratory & Cardiovascular Disorders

Case 3

 

Chief Complaint

(CC) :

A 75-year-old female reports experiencing pain in her chest while walking up steps today.

 

Subjective:

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 129/70, (HR) 72 and regular, (RR) 16 unlabored, temperature 98.8°F, oral pulse oximetry is 99%

General: obese female, alert, in no acute distress.

HEENT: Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. 

Respiratory: CTA AP&L

Neck/Throat: carotids are 2+ without bruits; thyroid is not palpable; no lymphadenopathy

Heart: 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.

Read and watch the lecture resources & materials below early in the week to help you respond to the discussion questions and to complete your assignment(s).

Read

• Rhoads, J., Demler, T. L., & Dlugasch, L. (2021). Advanced health assessment and diagnostic reasoning (4th ed.). Jones & Bartlett Learning. ISBN: 9781284170313

Watch:

• Watch the videos accompanied by each chapter from the publisher’s website (Rhoads & Wiggins Petersen, 2021):
  • Chapter 10: Sinus Inspection, Palpation, & PercussionLinks to an external site.
  • Chapter 10: Nose Inspection, Palpation, & PercussionLinks to an external site.
  • Chapter 10: Oral Inspection & Oral PalpationLinks to an external site.
  • Chapter 11: Respiratory PalpationLinks to an external site.
  • Chapter 11: Respiratory PercussionLinks to an external site.
  • Chapter 11: Respiratory AuscultationLinks to an external site.
  • Chapter 12: Cardiovascular Inspection, Palpation, & PercussionLinks to an external site.
  • Chapter 12: Cardiovascular AuscultationLinks to an external site.

 

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