PYA Nose, Mouth, Throat, and Neck Patient Case
Patient Case- you should embellish and add additional details to the patient case as needed to reflect f
PYA Nose, Mouth, Throat, and Neck Patient Case
Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:
Health history (Subjective data):
Mrs. Darby, a 71-year-old African American woman
Medications: diuretic for blood pressure
Allergies to animal dander and penicillin medications
HPI: Mrs. Darby is visiting the clinic today for a sore throat and stuffy nose that started 4 days ago and has gotten worse.
Ask Mrs. Davis more PQRSTU you think would be pertinent for her symptoms.
Physical Exam (objective Data):
Vital Signs: Oral Temp 37 C, HR 88 BPM, RR 20, and BP 138/72 mm Hg
Nose: green, thick, crusty discharge from both external nares. Both turbinate red and swollen internally. Nares are not patent. Document rest of nose assessment as normal/expected findings
Mouth: document mouth assessment as normal/expected findings
Throat/neck: Posterior oral pharynx reddened. Tonsillar lymph nodes enlarged and tender bilaterally – other lymph nodes and throat assessment document as normal/expected
