week 2 case

profileu lieber


  • a year ago
  • 9
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Case2.docx

Case 2

Chief Complaint (CC) 

A 45-year-old female presents with a complaint of an itchy red rash on her arms and legs for about two weeks.

Subjective

She has been going on a daily basis to the local YMCA with children for Summer camp.

 VS

(T) 98.3°F; (RR) 18; (HR) 70, regular; (BP) 118/74

 General

healthy-appearing female in no acute distress

 HEENT

EYES: no injection, no increase in lacrimation or purulent drainage; EARS: normal TM: Normal

 Skin

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.

Neck/Throat

No neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline.

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.