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Assignment: Chris Thomas Case Study

Assignment: Chris Thomas Case Study

 

Name: Chris Thomas                        Date of visit:                                       Time seen:

D.O.B:                                               SEX: Female          

Sex: F

Age: 35 years old

SUBJECTIVE:

CC: “Running nose and cough.”

HPI: CT is a 35-year-old female patient who came to the hospital complaining of a running nose and cough. She claims that the running nose and cough started a week before the present visit. However, two days ago she started experiencing a scratchy throat. She states that the cough is dry and comes now and then. The cough is the same in the morning and nights. She has been taking Tylenol to manage the symptoms, which she denies being of much help. The cough is worse in the morning when she is having a scratchy throat and dry mouth. She was diagnosed three years ago with seasonal allergies which she was managing using Zyrtec and Flonase, but she ran out of prescription a month ago.

  • Onset – A week before visiting the hospital.
  • Location- Throat and mouth
  • Duration – about one week
  • Character – scratchy throat that enhances coughing
  • Aggravating factors – dry mouth and scratchy throat in the morning
  • Alleviating factors – none that is known
  • Timing – the whole day

PMH:

Immunizations – Last flu shot – a year ago. Last tetanus toxoid injection – 3 years ago

Medications OTC – Tylenol 500mg PO

OTC- Motrin 200mg PO

ParaGard IUD, as a long-term birth control therapy, for the last six months

Allergies – Seasonal allergies and sulfur

SH– She takes around 3 to 4 glasses of wine on weekends. Denies using any illicit drugs. Denies smoking tobacco. Her hobby is walking.

Hospitalizations/Surgeries or traumatic injuries: Tonsillectomy

FH– CT is married with two children, a boy, and a girl.

Mother: 78 years old, with high blood pressure.

Father: Past away in a car accident. He also had asthma.

She denies knowing any paternal or maternal extended family history.

Current Health Maintenance (or Personal and Social Hx)– She is married with two children, a boy, and a girl. She is sexually active. She went to college and is currently working in a daycare.

Screenings & Self-Care – Denies ever having a TB skin test. Confirms breast examination regularly.

Diet: Her diet is quite simple but well balanced

Exercise: She exercises by walking her dog for 3 to 4 times a week for about 4 to 5 hours.

Sleep: She has enough sleep every night, with no disturbances.

Other Health Care Providers: Denies using any illicit drugs

Habits/Substance Use: Denies using any illicit drugs.

Safety: She lives with her husband and children in a very safe environment.

ROS: 

General: No recent weight gain or weight loss. No fever, weakness, tiredness, headache, dizziness or lightheadedness.

Skin: no lesions, moles, or unusual growths.

Eyes: denies any problem with her vision. Complains of itching eyes — no discharge or redness.

Ears: denies any ear problems.

Nose\Mouth\Throat: complains of a scratchy throat and a running nose.

Neck: Denies stiff neck or pain with movement.

Cardiovascular: no hypertension, heart problems or palpitation.

Respiratory: Denies any shortness of breath but confirms unproductive dry cough.

Circulatory: no anemia, past blood transfusion or bleeding problems.

Gastrointestinal: No diarrhea, constipation or hernia.

Genitourinary: last menstrual period- two weeks before the present hospital visit. Denies excessive urination.

Musculoskeletal: no joint pain or arthritis. No muscle cramps.

Lymphatic: no breast lump, nipple discharge or swollen glands.

Psychological: no anxiety, stress, or depression.

OBJECTIVE DATA

Physical examination

Weight –         Height –          BMI-   VS:      Temp,             B/P,     P,         R-

General: appears well groomed, in a stable mood. She maintains a good conversation and answers all the questions without hesitation.

Skin: no signs of lesions, or rashes or moles or unusual growth.

HEENT: the head appears normocephalic, with no lesions or lamps. Eyes: normal with white sclera and bilateral conjunctival edematous with cobblestone appearance clear discharges present. The pupils are equally dilated. Allergic shiners present bilaterally. Ears: appear to be clean. No signs of ear exudates. Nares: nasal mucosa is pale boggy with swollen copious clear discharges. Oropharynx: looking at the back of the mouth, there is injected pharynx with clear light yellow post nasal drip to posterior cobblestoning to pharynx

Neck\Lymphatic: no signs of swollen lymph nodes or pain. No stiffness of the neck

Cardiovascular: Regular heart rhythm and sounds. The S3 and S4 sounds are absent while S1 and S2 are present. No heart murmurs or carotid bruits.

Respiratory: Both lungs are in good condition. No signs of crackles or wheezing. Perfect breathing with no difficulties. The lung sounds are normal.

Gastrointestinal: Abdominal skin appears good with no marks or lesions. No abdominal pain on palpation.

Genitourinary: normal genitalia with no signs of herniation.

Musculoskeletal: no pain with joint movement. No back pains. Intact sensation to bilateral lower and upper extremities. Intact

Assignment Chris Thomas Case Study

Assignment Chris Thomas Case Study

sensation to bilateral lower and upper extremities. Full motion against resistance. A steady gait with continuously symmetric steps.

Psychological: Maintains good contact while answering questions. Very calm, and easy to follow instructions through all the physical examination. Does not seem to be anxious or stressed.

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Assessment

In most cases, diagnostic decisions are made based on patient history and clinical observation. However, further diagnostic tests can be ordered to rule out the differential diagnosis. Some of these tests include (Dains, Baumann, & Scheibel, 2016):

  • Allergy blood test
  • Skin prick test
  • Nasal cytology
  • rhino laryngoscopy

 

Differential Diagnosis

  1. Allergic Rhinitis (2019 ICD-10-CM Diagnosis Code J30.9): Allergic rhinitis is a common manifestation that affects about 10 to 30% of adults and children across the united states among other industrialized countries. The individuals below the age of 20 years have an 80% chance of developing allergic rhinitis. In 2012, in the US, 9% of children below 18 years and 7.5% of adults were reported to be manifested with this allergic condition (Seidman, 2015). Generally, the highest prevalence of allergic rhinitis, according to the WHO is in Africa and Latin America. Symptoms are self-limiting and can take between 7 to 10 days to resolve. Allergic rhinitis can result from inflammation of the mucous membranes of the eyes, nose, pharynx, middle ear, sinuses, and the eustachian tube. Usually, the nose is invariably involved while the other organs vary among different people (Wise et al., 2018). The inflammation is usually as a result of complex integration of the mediators of inflammation but most commonly triggered by the IgE mediated inflammatory response to the extrinsic proteins as a result of an allergen. The response leads to fatigue, malaise, and sleeplessness.

Rationale: Positive for cough, post nasal drip, pale and boggy mucosa, allergic shines, edematous conjunctiva and itchy eyes (Wise et al., 2018). Can be ruled out by lack of fatigue, malaise, drowsiness, earache, and sneezing.

  1. Acute Sinusitis (2019 ICD-10-CM Diagnosis Code J01.90): Sinusitis is a common health complication which affects approximately 1 out of 7 adults in America. Every year, over 30 million people are diagnosed with sinusitis. It is more prevalent in the early spring. According to NAMCS, about 14% of adults are usually diagnosed with episodic rhinosinusitis, which is the 5th most common health condition for antibiotic prescription (Solomon, & Rosenfeld, 2016). This condition accounts for 0.4% of the overall ambulatory diagnosis. The symptoms usually progress for about 4 to 12 weeks. Patients are diagnosed when they have 2 to 4 episodes per year.

Under physiological conditions, the sinuses are usually sterile. However, sinusitis presents when the retained mucus in the sinuses are infected (Solomon, & Rosenfeld, 2016). Alternatively, given that the sinuses and the nasal cavity are continuous, bacterial colonization of the nasopharynx can also contaminate the sterile sinuses (Rosenfeld et al., 2015). Usually, such bacteria are eliminated by mucociliary clearance. However, when this is altered, the bacteria may inoculate and cause infection. Generally, the pathophysiology of sinusitis can be explained in three ways, ciliary impairment, sinus Ostia and altered mucus quality and quantity.

Rationale: Positive for postnasal discharge, facial pain, cough, and pain over the cheek. Can be ruled out by lack of hyposmia, blocked nose, fever, fatigue and maxillary dental pain (Pynnonen et al., 2015).

  1. Rhinovirus (RV) Infection (2019 ICD-10-CM Diagnosis Code B34.8): Common cold is usually more prevalent during the temperate climates from September to April. Generally, rhinovirus infection presents all through the year. Most people infected by this condition are the elementary school and preschool-aged children. This age group has 3 to 8 colds per year, while adults and adolescents only have between 2 to 4 colds a year (Bashir et al., 2018). The symptoms usually progress for about 4 to 12 weeks. Patients are diagnosed when they have 2 to 4 episodes per year.

The human body’s natural human defense system to injury usually entails ICAM-1, that helps in leukocyte and endothelial cell binding. Rhinovirus uses ICAM-1 as a receptor for attachment, hence undermining this process (Drysdale, Mejias, & Ramilo, 2017). It also uses ICAM-1, during cell invasion for uncoating. This can lead to an inflammatory response which causes symptoms within 1 to 2 days.

Rationale: Positive for nasal discharge, facial and ear pressure, cough, and pale and boggy mucosa. Can be ruled out by lack of headache, sore throat, fever and hoarseness (Drysdale, Mejias, & Ramilo, 2017).

 

Final assessment/Diagnosis:

            Upon considering the patient history, clinical observation and some tests, not limited to Allergy blood test, allergy skin tests, total serum IgE and Total blood eosinophil count, the patient is diagnosed with allergic rhinitis. Given that she has seasonal allergies and his father had a history of asthma, the patient respiratory system is vulnerable especially when she visits a new place with new allergens. She also displayed symptoms of cough, post nasal drip, pale and boggy mucosa, allergic shines, edematous conjunctiva and itchy eyes which indicate that she is suffering from allergic rhinitis. In as much as the other differential diagnosis have almost the same presenting signs, some other important aspects such as lack of fatigue, malaise, drowsiness, earache, and sneezing rule out their diagnosis.

 

Plan: Follow-up and Patient education

  • Enhance the maximum reduction of the duration and severity of the symptoms.
  • Prevent development of complication as a result of a poorly managed condition such as eustachian tube dysfunction, otitis media, and chronic sinusitis.
  • Diagnosis should be made based on the physical examination findings, clinical observation, and the collected lab results.
  • Treatment will depend on the findings; however, the patient can be given drugs such as Motrin 200mg PO to manage the symptoms, in addition to immunotherapy (Wise et al., 2018).
  • Patient Education:
  1. Educate the patient on the environmental control measures such as avoiding allergens that can trigger an attack.
  2. The patient should be educated on the benefits of following the prescription for effective care outcome.
  3. The patient should stay warm.
  • No referrals are needed at this point.
  • The patient should seek medical attention in case of undesired side effects of the drugs or when the symptoms become more severe and persistent.

Looking at the back of the mouth, there is injected pharnx with clear light yellow post nasal drip to posterior cobblestoning to pharynx.
nasal mucosa was pale boggy with swollen copious clear discharges.
bilateral conjuctival odematous with cobblestone appearance clear discharges present. allegic shiners present billaterally.

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