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
57-year-old man presents to the office with a complaint of left ear drainage
since this morning.
A
45-year-old female presents with a complaint of an itchy red rash on her arms
and legs for about two weeks.
A
11-year-old female patient complains of red left eye and edematous eyelids.
Her mother states the child complains of “sand in my left eye.”
Subjective
Patient
stated he was having pulsating pain on left ear for about 3 days. After the
ear drainage the pain has gotten a little better.
She
has been going on a daily basis to the local YMCA with children for Summer
camp.
Patient
noticed redness three days ago. Denies having any allergies. Symptoms have
gotten worse since she noticed having the problem.
Objective Data
VS
(T) 99.8°F;
(RR) 14; (HR) 72; (BP) 138/90
(T)
98.3°F; (RR) 18; (HR) 70, regular; (BP) 118/74
(T)
98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb.
General
well-developed,
healthy male
healthy-appearing
female in no acute distress
well-developed,
healthy, 11 years old
HEENT
EAR:
(R) external ear normal, canal without erythema or exudate, little bit of
cerumen noted, TM- pearly grey, intact with light reflex and bony landmarks
present; (L) external ear normal, canal with white exudate and crusting, no
visualization of tympanic membrane or bony landmarks, no light reflex EYE:
bilateral anicteric conjunctiva, (PERRLA), EOM intact. NOSE: nares are patent
with no tissue edema. THROAT: no lesions noted, oropharynx moderately
erythematous with no postnasal drip.
EYES:
no injection, no increase in lacrimation or purulent drainage;
EARS: normal
TM: Normal
EYES:
very red sclera with dried, crusty exudates; unable to open eyes in the
morning with the left being worse than the right
Skin
No rashes
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
mild
edema with inflammation located on forearms, upper arms, and chest wall,
thighs and knees; primary lesions are a macular papular rash with secondary
linear excoriations on forearms and legs
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 initial post should be 500 words, formatted and cited
in current APA 7th style with support from at least 3 academic sources.
·
Turnitin similarity should be less than 14%
·
Quotes “…” cannot be used at a higher learning level for your assignments,
so sentences need to be paraphrased and referenced.
·
Acceptable references include scholarly journal articles or
primary legal sources (statutes, court opinions), journal articles, and books
published in the last five years. No websites to be referenced without
prior approval.
Textbook(s)
1. Rhoads, J., Demler, T. L., & Dlugasch, L. (2021). Advanced health
assessment and
diagnostic reasoning (4th ed.). Jones & Bartlett Learning.
ISBN: 9781284170313
Read
·
Rhoads, J., Demler, T. L., & Dlugasch, L. (2021).
·
o Chapter 7
o SLID_CH07.pptx
Download SLID_CH07.pptx
·
o Chapter 8
o SLID_CH08.pptx Download SLID_CH08.pptx
·
o Chapter 9
o SLID_CH09.pptx Download SLID_CH09.pptx
Supplemental Materials & Resources
·
Innovation Center for Community and Youth Development/Tides
Center. (2001). Exploring elements of healthy
communities. http://www.ethicalleadership.org/uploads/2/6/2/6/26265761/mapping_healthy_communities.pdf
Mapping_Healthy_Communities Download Mapping_Healthy_Communities
·
Visit the CINAHL
Complete under the A-to-Z
Databases on the University Library’s website, locate and read
the articles below:
o Oudshoorn, A.,
Ward-Griffin, C., Poland, B., Berman, H., Forchuk, C. (2013). Community health
promotion with people who are experiencing homelessness. Journal of Community Health Nursing,
30(1), 28-41. doi: 10.1080/07370016.2013.750204.
o Stark, M. A., Chase, C.,
DeYoung, A. (2010). Barriers to health promotion in community dwelling
elders. Journal of Community Health
Nursing, 27(4), 175-186. DOI: 10.1080/07370016.2010.515451

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