Question

Chief Complaint: difficulty swallowing

Patient: 32-yr-old female with a 5-day history of runny nose, sore throat, congestion and cough. The symptom that bothers her the most is the cough because it wakes her up at night.  She denies smoking. Her 5 year-old came home about a week ago with a “cold”.  She denies a history of asthma and allergies. She adds that since she is here she would like a refill on her SSRI. Her mood is “fine”.

PMH
Denies chronic diseases
Denies surgeries
Diet: vegetarian
Sleep 8 hours a night
Social: college degree, occupation administrative assistant, home owner and lives with husband and two children, bi-lingual English and Spanish, no religious affiliation.

Last Dental appointment 4 months ago, gets teeth cleaned 2-x year.
General: Denies weight loss, fever, fatigue, chills
Pul: + cough
GI: last BM today AM soft brown no blood.

Ht 5’ 2” Wt: 105 BP  100/60  HR 96 RR 14 Temp: 99.9

Gen: WNWD White female alert and anxious, coughing during interview.
HEENT: Sclera clear, EMO’s intact, PERRLA, TMs grey, canal clear bilaterally
Oral: Pharynx erythematous, tonsils + 2 bilateral uvula Uvula midline, good dentition, no order, buccal membranes moist pink no lesions  
Neck: no thyroid enlargement or nodules, full ROM, nontender no carotid bruits
Pul: course breath sounds bilaterally, no wheezing, no increase fremitus
CV: RRR S1 S2 no S3 or S4 no murmur
Neuro: CN 2 – 12 intact DTRs +2 bilaterally
Mood: anxious

Labs: Rapid Strep test negative

Assessment: Viral URI/Bronchitis

Plan:
Diagnostics: None
Rx: Robitussin with Codeine 1 – 2 teaspoons every 4 hours as needed for cough  
120 cc No Refills
Education: warm beverages or soups, tea with lemon, for sore throat, good hand washing, Motrin or Tylenol for fever, push fluids, can use OTC Sudafed as needed for runny nose
F/U: Return in 1 week if symptoms persists or get worse

Question: Using the case study write a summary of the case in the clinical setting.

Question: Briefly outline the essential elements of a case presentation (summary) described and note which of the NONPF core competencies you are demonstrating in constructing an effective/profession case presentation.

Answer 1

Case study:
summary:
Introduction:
32-year-old female patient with the chief compliment of difficulty swallowing. the patient has a history of runny nose, sore throat, congestion, and cough. couth bother patient especially night time. the patient has a history of asthma and allergies.
Main course:
The patient has allergic asthma, it occurs when the patient immune system overacting to alleged. the patient is on SSRI followup. patient symptoms of runny nose, sore throat. congestion and cough and difficulty swallowing. an asthma attack causes a nighttime cough that interferes with sleep. patient general condition is normal except low-grade fever. he oral assessment reveals viral URI/bronchitis. a patient experiencing these symptoms due to upper respiratory infection and asthma. a patient child with cold may be due to hereditary of an asthma attack or environmental factor. because asthma has a strong genetic component. oral examination shows pharynx erythematous and tonsils 2+ bilateral uvula midline. it causes her difficulty swallowing.. both asthma attacks and bronchitis cause the same symptoms. allergens from upper airway lymphoid enlargement of the tonsils obstruct the airway. it makes difficulty swallowing. Robitussin for a patient with codeine as an expectorant helps loosen the congestion and rescue the cough and reduce common cold, infection, and allergies. patient education is important about warm beverages or soups soothes the throat and loosens the secretion. good hand washing prevents infection. Motrin or Tylenol reduces fever. push fluids improve hydration. otc Sudafed for runny nose safe and effective for nasal congestion and relieve symptoms of nasal passage and pain.
The patient has to come for review after one week if symptoms persist.