Patient MK is a 20 year old Caucasian male student. He was presented to the Wellness Center with complaints of a migraine headache. This case will be presented in my abnormal assessment paper. Clinical Objectives. 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12, …show more content…
She was a” walk in” into the Wellness Center with complaints of cough and sore throat. She thought it would get better, but after four days she is not feeling better. She denies having a fever aches and chills. Patient denies earache, pressure and or pain in the sinus areas. Patient denies postnasal drip, stomachache, nausea, vomiting, and/or diarrhea. VS BP 116/62 P72 Temp 98.2 R18, I performed a HEENT exam on this patient. Her throat is red and difficult to visualize her tonsils. At the base of her right lung, upon auscultation Rhonchi can be heard. Her voice is raspy; she claims this is not her normal voice. She has a nonproductive cough, and when palpated no lumps or masses felt along the jaw line and or neck area. I spoke to my preceptor after gathering my information, I asked her to reassess the patients lungs and throat to confirm my findings. After collaboration with my preceptor, we diagnosed her with Bronchitis and Laryngitis. The prescription was given for Zithromax 250 mg by mouth starting with 500mg the first day then, 250 mg for 5 days. I explained the directions of the medication. I instructed the patient to return the Wellness Center on Monday if she is not feeling better. I instructed her to raise the head of the bed, increase her fluid intake, good hand washing, purell her hands, and cough in the bend of her arm. I was able to reeducate this patient on ways to decrease the spread of germs. Clinical Objectives