Throat, Respiratory & Cardiovascular Disorders

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Throat, Respiratory & Cardiovascular Disorders

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 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.

 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 initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.