COURSE:

NGR 6002C: Advanced Health Assessment and Diagnostic

CC:“I have a terriblecold”

HPI:15-year-old female has had 2-3 weeks of cold symptoms. She had had nasal congestion and runny nose with green discharge. Her cough is productive, persistent and produces green sputum. The cough is worse when lying down or when patient is active. She has tried cough drops and chloraseptic spray with little relief. She has had an intermittent headache that is generalized, is not associated with any precipitating events, is dull in nature and is relieved with Tylenol. She denies fever, vomiting, rash, decreased oral intake, shortness of breath. She has had difficulty sleeping due to nasal congestions and presence of cough. Her sister was diagnosed with pneumonia 2 weeks previously and mother is concerned that patient has the same. She presents during this visit with her mother. PMH:Seasonal allergies Immunizations: Up to date on immunizations though has not yet received seasonal influenza vaccine.

SOLUTION

Identify the Case #: 1 (15 year-old female)

Primary/Working Diagnosis: Acute Bacterial Sinustis

Pertinent Findings & Citation (leave double spaced):

Pressure sensation accompanied by facial pain. Noticeable tenderness when palpitating sinuses with complaints of intermittent headache; the headache is eased by OTC Tylenol. Patient reports purulent green nasal discharge. Persistent cough, green phlegm, sore throat, and nasal congestion. Cold symptoms that have been consistent for the past 2-3 weeks. Pertinent negatives: Denies fever, ear pain, loss of smell, ear pressure, and tooth pain (Bickley et al., 2021a, pg. 477)

DD #1: Asthma

Findings & Citation (leave double spaced): 

Productive and persistent cough for 2-3 weeks. Has a history of seasonal allergies…..…please purchase this case study solution for $10 only