| Category of Data | Data |
| Patient Information | M.B. 30 y/o WF married, employed as a secretary and has two children |
| Setting | Urgent Care/Emergency Room |
| Chief Complaint | Pain on the right side of face and right upper teeth for 2days. Nasal and sinus congestion (commonly occurs in the spring), greenish color nasal discharge. Feverish and pain worsen with bending, slight cough. Denies chest pain. |
| Past Medical History/Social History | Generally healthy, hospitalizations: Childbirth Married fro 8 years, a pack a day smoker for 10 years |
| Labs and Exam Data | BP: 120/80, P-80, R-18, T-98.6 Nasal mucosa: inflamed and edematous; purulent discharge from medial meatus, throat non-inflammed, cobblestoning of the posterior oropharynx, LUNGS: CTA; FACE: transillumination reveals opacification of the right maxillary sinuses |
| General Survey Data | 50 y/o Recurring sore throat, No chills or sweats; pain in upper teeth, non productive |
| Pertinent Health History | Sinus problems; takes Loratidine for her sinus problems |
Answer these questions related to the case study above and post to the discussion board. Please write in your own words (minimal direct quotes).
- Based on the data, what do you think the medical diagnosis would be? Support your diagnosis with the signs and symptoms and a reference.
- What information is missing and necessary to make a medical diagnosis? What additional information do you need to complete your database?
- What would you recommend the patient do with her medication regimen based on her symptoms? Provide resource information (website, article, book, etc.) for your patient regarding her medication regimen.
- What patient education topics would be appropriate for M.B.? Select one topic and provide an outline of your teaching plan (with at least one reference). Click here for example of an outline.
- What psychological, social, or physical issues might you consider when assessing/caring for M.B. and what interventions are indicated?
- Please do not duplicate a classmate’s topic or reference information.
Provide feedback to your classmates regarding their answers to EACH of the above questions, do you agree with their answers? Why or why not? Provide references in correct APA format that support your feedback.
All students should receive at least one response to their Discussion response. Please review the DQ before posting to ensure that another person has not already responded.
Please write in your own words.
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