Diagnostic and clinical reasoning paper Assignment1

Diagnostic and clinical reasoning paper Assignment
Medical diagnosis: Allergic Rhinitis
Student Name :
Typhon Case ID: 2063-20190730-008
Date :
Subjective Data
 Chief complaint
A 25 years old woman came with the complaints of runny nose, itchy eyes, and redness since
11/2018.
 History of present illness
A 25 years old woman came with the complaints of the runny nose since 11/2018. She is
suffering from a runny nose for the past 8 months. She also has complaints of itchy eyes and
redness. She said that the symptoms are stable and she has taken Flonase as per her friend’s
advice. She also used "Salt sweet therapy" which is considered to be a natural therapy. She
underwent the treatment on the 20th of July. She explained that she is relieved from the
symptoms. She works in Walmart as a night stocker. She also reports that her symptoms
increases in the work environment. On admission, she has no complaints of fever, chest pain,
headache, Nausea, and vomiting. No changes in bowel movement, weight, and sweating.
 Past Medical history

She has no complaints about a specific illness in the past. Has no history of respiratory illness
or infection.
 Allergies
The patient is allergic to Morphine and penicillin.
Medications
She is on Tab. Claritin – D administered orally, on the increase of symptoms once daily and
Tab. Flonase 50mcg nasal spray, one spray in each nostril twice daily.
 Social History
The factor that is closely related to the symptom is her work she works in Walmart. She used
to do night shifts. Her work place is dusty and clumsy. The patient has complaints of
increased symptom in her work place.
 Family History
She has no family history of any illness, infection and respiratory problems.
 Health Maintenance
Patient had HPV vaccine on 11/2011, Prevnar on 12/2017 and had Tdap on 03/2019; she also
underwent a eye examination on 11/2018. She has done Pap smear on 03/2017. She is on
Normal diet and had no vaccination in the past (Siu, 2016).
Review of Systems (ROS)
 General

The patient has no complaints of fever, chills, fatigue, and malaise.
 Skin
The patient has no itching, nail color changes, hair changes. She has no complaints of any
rashes.
 HEENT
The patient has no trauma, headache, vomiting, and dizziness on the head. No complaints of
pain, redness, tearing, discharge, vision loss, puffy eyes on eyes. No complaints of hearing
loss, tinnitus, earache, and discharge. Have complaints of stuffiness in nose, nasal discharge,
sneezing, itching, and epitasis. No complaints of any bleeding gums, sore throat, dry mouth,
and painful swallowing.
 Neck
No complaints of any lumps, pain, stiffness and swollen nodes
 Cardio- Vascular
No complaints of any palpitations, chest pain, DOE, orthopnea
 Respiratory
No complaints of any cough, sputum production, wheezing. Denies any Hx of TB
 Gastro-Intestinal
No complaints about any changes in appetite, nausea, vomiting, diarrhoea, constipation, and
heartburn.

 Genito-urinary
The patient has no complaints of any nocturia, polyuria, hematuria or incontinence.
 peripheral vascular
The patient has no history of blood clots, varicose veins, and oedema.
 Musculoskeletal
The patient has no complaints of any muscle pain, joint pain, joint swelling, joint redness or
tender points.
 Neurological
The patient has no complaints of any numbness, tingling, tremors, or history of CVA
 Endocrine
The patient has no complaints of any heat or cold intolerance, excessive thirst or hunger, and
polyuria.
 Psychological status
The patient has no complaints of any mood changes, anxiety or depression, and suicidal
ideation.
Objective data
 Physical examination
Data helps in diagnosing the patient's disease condition is as follows.

 Vital signs
Blood pressure - 119.0 / 80.0
Heart rate - 87.0 bpm
Respiratory rate - 16.0 rpm
Temperature - 97.4 degrees F Ht
Weight during admission - 163 lbs
Saturation - 99.0%
General statement
 Skin
Skin is warm and dry
 HEENT
NC/AT, Normal hair pattern on head assessment, PERRLA, EOMI, nonicteric sclera on eye
examination, External ears with no lesions, Moist erythematous mucous membranes, no or
pharyngeal exudates, nasal mucosa edematous with whitish nasal discharge.
 Neck
Supple, NT, FROM
 Cardiovascular
RRR, no m/r/g, S1/S2 present
 Respiratory

Lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, non-labored breathing, no use of
accessory of muscles of respiration.
 Abdomen
+BS, non-tender to palpation, no masses, no HSM
 peripheral vascular
Has no cyanosis, clubbing, edema
 Neurological exam
CN 2-12 intact, no focal neuro deficits
 Psychological Assessment
The patient is Judgmental, insight intact, NL mood, affect
 Diagnostic tests
Diagnostics test are not done for the patient. Physical examination and patient history aids in
the process of diagnosing.
Assessment
A 25 years old woman came with the complaints of runny nose, itchy eyes, and redness since
11/2018. The patient is diagnosed to have Allergic rhinitis.
Plan
 Therapeutic
"Salt sweet therapy “is supportive

 Educational
The patient was instructed to transfer her work to another department
Consultation
Referred to ENT and Allergist
Clinical decision making
 Pathophysiology
Allergic rhinitis is caused due to the allergens in the environment. Allergens enter the
respiratory tract and cause inflammation (Ferastraoaru,2019). Inflammation results in the
signs and symptoms like runny nose, redness in eyes, nasal stuffiness, rhino rhea, and
sneezing, itching, epitasis (Ellis, 2015).
 Pharmacology
The patient is on Tab. Flonase 50mcg nasal spray, one spray in each nostril twice daily. It is a
corticosteroid relieves the symptoms.
Clinical Diagnostic Reasoning
Objective and subjective data helps in clinical diagnosis. It also provides the frame work of
care plan. Elements that support the plan of care are Physical examination and investigation
(Wheatley, 2015).
Ethical Concerns

Code of ethics used in the care of the patient is equality. It is the primary professional ethics
need to follow while caring for the patients. All the resources need to be used equally
(Kangasniemi,2015)
Barriers to Care
Financial, social and occupational barriers that have made the patient to avoid the medical
care. The patient is suffering from a runny nose for 8 months and she didn’t seek medical
advice due to the barriers. The actual barrier is the occupation. The potential barrier would be
her financial status (Kullgren, 2012).
References
Siu, A. L., Bibbins-Domingo, K., Grossman, D. C., Davidson, K. W., Epling, J. W., García,
F. A., ... & Landefeld, C. S. (2016). Screening for chronic obstructive pulmonary disease: US
Preventive Services Task Force recommendation statement. Jama, 315(13), 1372-1377
https://jamanetwork.com/journals/jama/article-abstract/2510917
Wheatley, L. M., & Togias, A. (2015). Allergic rhinitis. New England Journal of
Medicine, 372(5), 456-463 https://www.nejm.org/doi/full/10.1056/NEJMcp1412282
Ellis, A. K., Soliman, M., Steacy, L., Boulay, M. È., Boulet, L. P., Keith, P. K., ... &
Neighbour, H. (2015). The Allergic Rhinitis–Clinical Investigator Collaborative (AR-CIC):
nasal allergen challenge protocol optimization for studying AR pathophysiology and
evaluating novel therapies. Allergy, Asthma & Clinical Immunology, 11(1), 16
https://aacijournal.biomedcentral.com/articles/10.1186/s13223-015-0082-0
Ferastraoaru, D. E., Takahashi, T., & Rosenstreich, D. (2019). Potential utility of nasal lavage
microparticle analysis in the diagnosis and pathophysiology of local allergic rhinitis. Journal

of Allergy and Clinical Immunology, 143(2), AB212
https://onlinelibrary.wiley.com/doi/full/10.1111/all.13770
Jeffrey T Kullgren., Catherine G McLaughlin, Nandita Mitra, and Katrina Armstrong.
(2012). Nonfinancial Barriers and Access to Care for U.S. Adults. Health service research
462–485, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3393009/
Kangasniemi, M., Pakkanen, P., & Korhonen, A. (2015). Professional ethics in nursing: an
integrative review. Journal of advanced nursing, 71(8), 1744-1757
https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12619