Case Scenario: Chief Complaint (CC)
A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents to the clinic with a cough he has had for the past 2 weeks.
Subjective: denies chest pain, denies night sweats, admits to having a fever but does not know the temp.
VS: (BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), 02 sat 98% on room air.
General: patient appears tired; skin color pale, patient is diaphoretic and sweaty, height 5'3"; weight 175 lbs
HEENT EYES: no injection, no increase in lacrimation or purulent drainage;
EARS: normal
TM: Normal
NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right.
Obstructed air passages Respiratory lung crackles in LLL, no wheezes or rhonchi noted; does not clear with coughing; dullness to percussion over the LLL; shallow respirations and is 30, accessorymuscles use not present
Neck/Throat: no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline
Heart: Regular rate and rhythm, no murmur, S3, or S4post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic source
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic examination do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.