Assignment 3: Nasal congestion
Assignment 3: Nasal congestion
Review the documented subjective and objective history in the
two rooms below, Provide scholarly support to identify a
differential diagnosis based on the reported findings. Include
additional subjective or objective data that would support this
diagnosis for each.
Room 1:
Demographics:
2-year-old male, Richie, brought to the clinic by his mother Rachel
Regis for nasal congestion and tugging at his left ear.
Subjective:
Chief complaint (CC): “he has nasal congestion and he has been
tugging on his left ear”
HPI: The patient presents accompanied by his mother who gives
the history. Richie has had nasal congestion for the past 5 days. He
has been slightly irritable but he has been eating as usual until
this morning. The mother reports he woke up suddenly at 5 am
crying and she was unable to console him with the usual
measures. He was extremely irritable and refusing the water that
the mother offered him. She noticed that he was tugging on his
left ear intermittently. He felt warm as if he has a fever but the
mother did not have a thermometer at home to check his
temperature.
Objective:
Vitals: T-103.5, BP- 122/85, P-101, R-30
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